- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $86.63 / $86.63 / $87.06
| Facility | | $86.63 | $86.63 | $87.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $65.23 / $72.09 / $113.99
| Professional | | $65.23 | $72.09 | $113.99 |
- Facility/Professional
- Professional
- Modifier
- 25
- Low / Median / High Price
- $209.60 / $209.60 / $245.55
| Professional | 25 | $209.60 | $209.60 | $245.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.56 / $100.58 / $167.11
| Professional | | $72.56 | $100.58 | $167.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.56 / $101.07 / $167.11
| Professional | | $72.56 | $101.07 | $167.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.72 / $107.31 / $210.69
| Professional | | $78.72 | $107.31 | $210.69 |