- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.22 / $146.75 / $274.00
| Professional | | $72.22 | $146.75 | $274.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $106.38 / $139.38 / $176.40
| Facility | | $106.38 | $139.38 | $176.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $220.70 / $350.87 / $350.87
| Professional | | $220.70 | $350.87 | $350.87 |
- Facility/Professional
- Professional
- Modifier
- 25
- Low / Median / High Price
- $111.38 / $111.38 / $111.38
| Professional | 25 | $111.38 | $111.38 | $111.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20.00 / $106.38 / $132.19
| Facility | | $20.00 | $106.38 | $132.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.00 / $24.81 / $132.19
| Professional | | $19.00 | $24.81 | $132.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.70 / $66.63 / $108.23
| Professional | | $36.70 | $66.63 | $108.23 |