- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.50 / $120.23 / $281.84
| Professional | | $95.50 | $120.23 | $281.84 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $67.61 / $67.61 / $83.18
| Facility | 26 | $67.61 | $67.61 | $83.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.50 / $204.17 / $263.03
| Professional | | $95.50 | $204.17 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $194.98 / $295.12
| Professional | | $162.18 | $194.98 | $295.12 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $67.61 / $67.61 / $83.18
| Facility | 26 | $67.61 | $67.61 | $83.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $257.04 / $309.03
| Professional | | $158.49 | $257.04 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $144.54 / $204.17
| Professional | | $112.20 | $144.54 | $204.17 |