- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.97 / $79.20 / $118.67
| Professional | | $72.97 | $79.20 | $118.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.37 / $48.37 / $129.87
| Professional | | $48.37 | $48.37 | $129.87 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $48.37 / $48.37 / $57.50
| Facility | 26 | $48.37 | $48.37 | $57.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.81 / $116.88 / $346.74
| Professional | | $67.81 | $116.88 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $48.37 / $48.37 / $57.50
| Facility | 26 | $48.37 | $48.37 | $57.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.53 / $129.87 / $197.59
| Professional | | $79.53 | $129.87 | $197.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.56 / $130.47 / $158.44
| Professional | | $105.56 | $130.47 | $158.44 |