- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $83.51 / $104.71 / $129.41
| Facility | | $83.51 | $104.71 | $129.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $68.34 / $104.96 / $144.53
| Professional | | $68.34 | $104.96 | $144.53 |
- Facility/Professional
- Professional
- Modifier
- 25
- Low / Median / High Price
- $209.41 / $209.41 / $209.41
| Professional | 25 | $209.41 | $209.41 | $209.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.73 / $152.77 / $260.41
| Professional | | $97.73 | $152.77 | $260.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.82 / $122.33 / $144.65
| Professional | | $95.82 | $122.33 | $144.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.22 / $136.84 / $194.70
| Professional | | $105.22 | $136.84 | $194.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.50 / $132.46 / $196.90
| Professional | | $101.50 | $132.46 | $196.90 |