- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.09 / $178.77 / $244.91
| Professional | | $113.09 | $178.77 | $244.91 |
- Facility/Professional
- Professional
- Modifier
- 25
- Low / Median / High Price
- $188.18 / $287.39 / $338.10
| Professional | 25 | $188.18 | $287.39 | $338.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.06 / $158.06 / $210.22
| Professional | | $158.06 | $158.06 | $210.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.60 / $147.60 / $195.17
| Professional | | $147.60 | $147.60 | $195.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.78 / $197.75 / $376.82
| Professional | | $170.78 | $197.75 | $376.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.44 / $272.95 / $410.40
| Professional | | $133.44 | $272.95 | $410.40 |