- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.79 / $95.50 / $190.55
| Professional | | $70.79 | $95.50 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.44 / $87.10 / $165.96
| Professional | | $72.44 | $87.10 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.69 / $102.33 / $199.53
| Professional | | $41.69 | $102.33 | $199.53 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $44.67 / $123.03 / $123.03
| Facility | 26 | $44.67 | $123.03 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.67 / $100.00 / $645.65
| Professional | | $44.67 | $100.00 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.69 / $85.11 / $169.82
| Professional | | $41.69 | $85.11 | $169.82 |