- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $101.27 / $124.54 / $234.09
| Facility | | $101.27 | $124.54 | $234.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.77 / $124.54 / $157.41
| Professional | | $101.77 | $124.54 | $157.41 |
- Facility/Professional
- Professional
- Modifier
- 25
- Low / Median / High Price
- $24.50 / $68.90 / $175.00
| Professional | 25 | $24.50 | $68.90 | $175.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.94 / $187.14 / $228.75
| Professional | | $143.94 | $187.14 | $228.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $330.02 / $761.19 / $761.19
| Facility | | $330.02 | $761.19 | $761.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.04 / $146.35 / $268.50
| Professional | | $105.04 | $146.35 | $268.50 |