- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.92 / $141.76 / $213.93
| Professional | | $104.92 | $141.76 | $213.93 |
- Facility/Professional
- Professional
- Modifier
- 25
- Low / Median / High Price
- $261.39 / $261.39 / $424.00
| Professional | 25 | $261.39 | $261.39 | $424.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.87 / $198.11 / $271.98
| Professional | | $143.87 | $198.11 | $271.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.90 / $147.90 / $147.90
| Professional | | $147.90 | $147.90 | $147.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.50 / $272.99 / $392.71
| Professional | | $194.50 | $272.99 | $392.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.77 / $162.19 / $175.74
| Professional | | $121.77 | $162.19 | $175.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.76 / $225.92 / $343.01
| Professional | | $114.76 | $225.92 | $343.01 |