- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $156.38 / $156.38 / $182.91
| Facility | | $156.38 | $156.38 | $182.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $99.15 / $143.72 / $236.10
| Professional | | $99.15 | $143.72 | $236.10 |
- Facility/Professional
- Professional
- Modifier
- 25
- Low / Median / High Price
- $261.39 / $261.39 / $261.39
| Professional | 25 | $261.39 | $261.39 | $261.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.90 / $147.90 / $147.90
| Professional | | $147.90 | $147.90 | $147.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.63 / $154.68 / $189.80
| Professional | | $118.63 | $154.68 | $189.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.51 / $189.61 / $243.80
| Professional | | $139.51 | $189.61 | $243.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.87 / $177.46 / $270.22
| Professional | | $129.87 | $177.46 | $270.22 |