- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $154.88 / $288.40
| Professional | | $114.82 | $154.88 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $107.15 / $208.93
| Professional | | $107.15 | $107.15 | $208.93 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $107.15 / $107.15 / $131.83
| Facility | 26 | $107.15 | $107.15 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.49 / $190.55 / $323.59
| Professional | | $117.49 | $190.55 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.09 / $229.09 / $346.74
| Professional | | $229.09 | $229.09 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $107.15 / $107.15 / $131.83
| Facility | 26 | $107.15 | $107.15 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $295.12 / $354.81
| Professional | | $181.97 | $295.12 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.82 / $147.91 / $229.09
| Professional | | $128.82 | $147.91 | $229.09 |