- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.70 / $161.71 / $177.89
| Professional | | $101.70 | $161.71 | $177.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.47 / $60.47 / $108.31
| Professional | | $60.47 | $60.47 | $108.31 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $60.47 / $60.47 / $74.75
| Facility | 26 | $60.47 | $60.47 | $74.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.31 / $175.97 / $279.36
| Professional | | $108.31 | $175.97 | $279.36 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $60.47 / $60.47 / $74.75
| Facility | 26 | $60.47 | $60.47 | $74.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.84 / $130.81 / $238.85
| Professional | | $71.84 | $130.81 | $238.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.39 / $151.04 / $190.56
| Professional | | $92.39 | $151.04 | $190.56 |