- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.28 / $95.50 / $128.82
| Professional | | $81.28 | $95.50 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $28.18 / $33.11 / $41.69
| Professional | 26 | $28.18 | $33.11 | $41.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.82 / $158.49 / $158.49
| Professional | | $128.82 | $158.49 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $44.67 / $56.23 / $56.23
| Professional | 26 | $44.67 | $56.23 | $56.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.50 / $134.90 / $288.40
| Professional | | $95.50 | $134.90 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $33.88 / $47.86 / $102.33
| Professional | 26 | $33.88 | $47.86 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.50 / $144.54 / $295.12
| Professional | | $95.50 | $144.54 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $33.11 / $53.70 / $104.71
| Professional | 26 | $33.11 | $53.70 | $104.71 |