- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $146.13 / $146.13 / $172.25
| Facility | | $146.13 | $146.13 | $172.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.15 / $146.13 / $528.00
| Professional | | $105.15 | $146.13 | $528.00 |
- Facility/Professional
- Professional
- Modifier
- 25
- Low / Median / High Price
- $261.39 / $261.39 / $261.39
| Professional | 25 | $261.39 | $261.39 | $261.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.38 / $207.91 / $336.00
| Professional | | $176.38 | $207.91 | $336.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.90 / $147.90 / $336.00
| Professional | | $147.90 | $147.90 | $336.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.90 / $147.90 / $336.00
| Professional | | $147.90 | $147.90 | $336.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.72 / $216.73 / $411.37
| Professional | | $130.72 | $216.73 | $411.37 |