- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $94.86 / $107.51 / $126.49
| Facility | | $94.86 | $107.51 | $126.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.65 / $127.30 / $382.03
| Professional | | $60.65 | $127.30 | $382.03 |
- Facility/Professional
- Professional
- Modifier
- 25
- Low / Median / High Price
- $128.72 / $128.72 / $128.72
| Professional | 25 | $128.72 | $128.72 | $128.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.81 / $101.81 / $109.61
| Professional | | $101.81 | $101.81 | $109.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.03 / $142.03 / $297.08
| Professional | | $142.03 | $142.03 | $297.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.65 / $148.77 / $292.74
| Professional | | $86.65 | $148.77 | $292.74 |