- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $112.20 / $138.04
| Professional | | $79.43 | $112.20 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Professional | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $97.72 / $97.72 / $97.72
| Facility | | $97.72 | $97.72 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.18 / $97.72 / $186.21
| Professional | | $83.18 | $97.72 | $186.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6.61 / $60.26 / $95.50
| Facility | | $6.61 | $60.26 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $93.33 / $131.83
| Professional | | $60.26 | $93.33 | $131.83 |