- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $76.09 / $86.25 / $101.47
| Facility | | $76.09 | $86.25 | $101.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.92 / $88.41 / $134.94
| Professional | | $20.92 | $88.41 | $134.94 |
- Facility/Professional
- Professional
- Modifier
- 25
- Low / Median / High Price
- $20.57 / $101.95 / $101.95
| Professional | 25 | $20.57 | $101.95 | $101.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.56 / $69.56 / $88.98
| Professional | | $69.56 | $69.56 | $88.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.67 / $115.67 / $241.16
| Professional | | $115.67 | $115.67 | $241.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.86 / $105.02 / $237.64
| Professional | | $63.86 | $105.02 | $237.64 |