- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.87 / $174.88 / $587.27
| Professional | | $113.87 | $174.88 | $587.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.28 / $87.28 / $182.45
| Professional | | $87.28 | $87.28 | $182.45 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $87.28 / $87.28 / $107.90
| Facility | 26 | $87.28 | $87.28 | $107.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.63 / $182.45 / $263.58
| Professional | | $122.63 | $182.45 | $263.58 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $87.28 / $87.28 / $107.90
| Facility | 26 | $87.28 | $87.28 | $107.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.73 / $200.79 / $317.17
| Professional | | $123.73 | $200.79 | $317.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.43 / $123.43 / $206.79
| Professional | | $123.43 | $123.43 | $206.79 |