- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $358.27 / $358.27 / $358.27
| Facility | | $358.27 | $358.27 | $358.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.90 / $217.57 / $330.72
| Professional | | $151.90 | $217.57 | $330.72 |
- Facility/Professional
- Professional
- Modifier
- 25
- Low / Median / High Price
- $246.91 / $463.84 / $463.84
| Professional | 25 | $246.91 | $463.84 | $463.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $186.36 / $424.93 / $932.97
| Facility | | $186.36 | $424.93 | $932.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.36 / $238.10 / $324.35
| Professional | | $186.36 | $238.10 | $324.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.57 / $328.17 / $520.49
| Professional | | $182.57 | $328.17 | $520.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $254.31 / $330.09 / $411.01
| Professional | | $254.31 | $330.09 | $411.01 |