- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $333.08 / $333.08 / $333.08
| Facility | | $333.08 | $333.08 | $333.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.63 / $164.48 / $300.00
| Professional | | $110.63 | $164.48 | $300.00 |
- Facility/Professional
- Professional
- Modifier
- 25
- Low / Median / High Price
- $216.61 / $216.61 / $240.52
| Professional | 25 | $216.61 | $216.61 | $240.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $182.48 / $321.73 / $932.97
| Facility | | $182.48 | $321.73 | $932.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.16 / $175.73 / $239.56
| Professional | | $137.16 | $175.73 | $239.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.82 / $248.85 / $384.31
| Professional | | $134.82 | $248.85 | $384.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $156.54 / $219.21 / $311.14
| Professional | | $156.54 | $219.21 | $311.14 |