- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $628.66 / $628.66 / $628.66
| Facility | | $628.66 | $628.66 | $628.66 |
- Facility/Professional
- Facility
- Modifier
- 25
- Low / Median / High Price
- $330.33 / $594.79 / $613.91
| Facility | 25 | $330.33 | $594.79 | $613.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.85 / $52.50 / $135.00
| Professional | | $38.85 | $52.50 | $135.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $49.07 / $62.61 / $72.81
| Professional | | $49.07 | $62.61 | $72.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,282.37 / $2,282.37 / $2,282.37
| Facility | | $2,282.37 | $2,282.37 | $2,282.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.12 / $52.51 / $82.22
| Professional | | $42.12 | $52.51 | $82.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,282.37 / $2,282.37 / $2,282.37
| Facility | | $2,282.37 | $2,282.37 | $2,282.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.12 / $56.18 / $82.22
| Professional | | $42.12 | $56.18 | $82.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.12 / $60.33 / $121.35
| Professional | | $44.12 | $60.33 | $121.35 |