- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $186.21 / $218.78 / $218.78
| Facility | | $186.21 | $218.78 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.82 / $165.96 / $346.74
| Professional | | $128.82 | $165.96 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- 25
- Low / Median / High Price
- $134.90 / $354.81 / $354.81
| Professional | 25 | $134.90 | $354.81 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $213.80 / $213.80
| Professional | | $181.97 | $213.80 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $147.91 / $234.42
| Professional | | $147.91 | $147.91 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $234.42 / $338.84
| Professional | | $177.83 | $234.42 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $234.42 / $407.38
| Professional | | $162.18 | $234.42 | $407.38 |