- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.91 / $153.66 / $208.48
| Professional | | $108.91 | $153.66 | $208.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.12 / $128.16 / $160.19
| Professional | | $96.12 | $128.16 | $160.19 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $30.71 / $30.71 / $30.71
| Facility | 26 | $30.71 | $30.71 | $30.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.33 / $151.88 / $287.89
| Professional | | $89.33 | $151.88 | $287.89 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $61.36 / $118.08 / $118.08
| Facility | 26 | $61.36 | $118.08 | $118.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.60 / $148.52 / $1,025.66
| Professional | | $105.60 | $148.52 | $1,025.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.28 / $137.46 / $263.20
| Professional | | $104.28 | $137.46 | $263.20 |