- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.20 / $125.89 / $218.78
| Professional | | $91.20 | $125.89 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- 25
- Low / Median / High Price
- $114.82 / $131.83 / $218.78
| Professional | 25 | $114.82 | $131.83 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $120.23 / $144.54
| Professional | | $109.65 | $120.23 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.49 / $117.49 / $154.88
| Professional | | $117.49 | $117.49 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $154.88 / $194.98
| Professional | | $131.83 | $154.88 | $194.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $91.20 / $151.36 / $151.36
| Facility | | $91.20 | $151.36 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.20 / $131.83 / $257.04
| Professional | | $91.20 | $131.83 | $257.04 |