- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.20 / $103.79 / $570.83
| Professional | | $70.20 | $103.79 | $570.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.89 / $58.89 / $150.38
| Professional | | $58.89 | $58.89 | $150.38 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $58.89 / $58.89 / $72.80
| Facility | 26 | $58.89 | $58.89 | $72.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.86 / $150.38 / $219.89
| Professional | | $90.86 | $150.38 | $219.89 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $58.89 / $58.89 / $72.80
| Facility | 26 | $58.89 | $58.89 | $72.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.59 / $163.36 / $264.95
| Professional | | $96.59 | $163.36 | $264.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.69 / $107.41 / $176.83
| Professional | | $100.69 | $107.41 | $176.83 |