- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.59 / $139.01 / $594.78
| Professional | | $113.59 | $139.01 | $594.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.63 / $183.50 / $183.50
| Professional | | $53.63 | $183.50 | $183.50 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $53.63 / $53.63 / $66.30
| Facility | 26 | $53.63 | $53.63 | $66.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.25 / $183.50 / $259.98
| Professional | | $108.25 | $183.50 | $259.98 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $53.63 / $53.63 / $66.30
| Facility | 26 | $53.63 | $53.63 | $66.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.19 / $195.55 / $315.37
| Professional | | $122.19 | $195.55 | $315.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.47 / $121.26 / $212.95
| Professional | | $119.47 | $121.26 | $212.95 |