- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $510.84 / $740.70 / $1,619.75
| Facility | | $510.84 | $740.70 | $1,619.75 |
- Facility/Professional
- Facility
- Modifier
- 25
- Low / Median / High Price
- $400.25 / $745.66 / $1,669.15
| Facility | 25 | $400.25 | $745.66 | $1,669.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54.02 / $70.90 / $503.10
| Professional | | $54.02 | $70.90 | $503.10 |
- Facility/Professional
- Professional
- Modifier
- 25
- Low / Median / High Price
- $67.64 / $116.68 / $641.25
| Professional | 25 | $67.64 | $116.68 | $641.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.00 / $126.00 / $126.00
| Professional | | $126.00 | $126.00 | $126.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.40 / $95.27 / $144.06
| Professional | | $67.40 | $95.27 | $144.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.83 / $116.61 / $186.99
| Professional | | $93.83 | $116.61 | $186.99 |