- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $128.57 / $184.00 / $402.91
| Facility | | $128.57 | $184.00 | $402.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.37 / $127.70 / $218.59
| Professional | | $73.37 | $127.70 | $218.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $111.42 / $165.14 / $380.10
| Facility | | $111.42 | $165.14 | $380.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $66.66 / $112.20 / $187.24
| Professional | | $66.66 | $112.20 | $187.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $139.38 / $139.38 / $139.38
| Facility | | $139.38 | $139.38 | $139.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.00 / $220.70 / $350.87
| Professional | | $112.00 | $220.70 | $350.87 |
- Facility/Professional
- Professional
- Modifier
- 25
- Low / Median / High Price
- $128.59 / $128.59 / $132.30
| Professional | 25 | $128.59 | $128.59 | $132.30 |