- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.60 / $65.05 / $107.12
| Professional | | $55.60 | $65.05 | $107.12 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $165.55 / $165.55 / $165.55
| Facility | 26 | $165.55 | $165.55 | $165.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $451.51 / $451.51 / $451.51
| Professional | | $451.51 | $451.51 | $451.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.37 / $129.84 / $300.83
| Professional | | $72.37 | $129.84 | $300.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $76.06 / $111.96 / $300.83
| Professional | | $76.06 | $111.96 | $300.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.27 / $108.15 / $246.59
| Professional | | $87.27 | $108.15 | $246.59 |