- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.20 / $133.62 / $437.02
| Professional | | $110.20 | $133.62 | $437.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.81 / $77.81 / $187.18
| Professional | | $77.81 | $77.81 | $187.18 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $77.81 / $77.81 / $96.20
| Facility | 26 | $77.81 | $77.81 | $96.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.80 / $187.18 / $259.30
| Professional | | $119.80 | $187.18 | $259.30 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $77.81 / $77.81 / $96.20
| Facility | 26 | $77.81 | $77.81 | $96.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.87 / $200.79 / $307.29
| Professional | | $119.87 | $200.79 | $307.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.10 / $123.88 / $211.06
| Professional | | $119.10 | $123.88 | $211.06 |