- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.15 / $148.66 / $213.93
| Professional | | $105.15 | $148.66 | $213.93 |
- Facility/Professional
- Professional
- Modifier
- 25
- Low / Median / High Price
- $97.77 / $153.05 / $205.00
| Professional | 25 | $97.77 | $153.05 | $205.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.82 / $126.82 / $158.88
| Professional | | $126.82 | $126.82 | $158.88 |
- Facility/Professional
- Professional
- Modifier
- 25
- Low / Median / High Price
- $133.02 / $133.02 / $133.02
| Professional | 25 | $133.02 | $133.02 | $133.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.27 / $156.80 / $188.74
| Professional | | $115.27 | $156.80 | $188.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.90 / $147.90 / $171.21
| Professional | | $147.90 | $147.90 | $171.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.98 / $141.21 / $207.81
| Professional | | $104.98 | $141.21 | $207.81 |