- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.44 / $104.71 / $223.87
| Professional | | $72.44 | $104.71 | $223.87 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $199.53 / $199.53 / $199.53
| Facility | 26 | $199.53 | $199.53 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $123.03 / $144.54
| Professional | | $123.03 | $123.03 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $144.54 / $380.19
| Professional | | $120.23 | $144.54 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.33 / $93.33 / $380.19
| Professional | | $93.33 | $93.33 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.20 / $109.65 / $239.88
| Professional | | $91.20 | $109.65 | $239.88 |