- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $97.37 / $126.40 / $221.87
| Facility | | $97.37 | $126.40 | $221.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.37 / $120.56 / $157.32
| Professional | | $97.37 | $120.56 | $157.32 |
- Facility/Professional
- Professional
- Modifier
- 25
- Low / Median / High Price
- $26.28 / $128.72 / $147.68
| Professional | 25 | $26.28 | $128.72 | $147.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.84 / $184.45 / $223.44
| Professional | | $161.84 | $184.45 | $223.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $287.58 / $657.54 / $657.54
| Facility | | $287.58 | $657.54 | $657.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.55 / $140.99 / $259.10
| Professional | | $92.55 | $140.99 | $259.10 |