- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.41 / $166.25 / $189.21
| Professional | | $114.41 | $166.25 | $189.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.81 / $36.81 / $214.00
| Professional | | $36.81 | $36.81 | $214.00 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $36.81 / $36.81 / $45.50
| Facility | 26 | $36.81 | $36.81 | $45.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $66.84 / $100.15 / $277.63
| Professional | | $66.84 | $100.15 | $277.63 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $36.81 / $36.81 / $45.50
| Facility | 26 | $36.81 | $36.81 | $45.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.00 / $214.00 / $345.26
| Professional | | $110.00 | $214.00 | $345.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $76.06 / $132.09 / $368.78
| Professional | | $76.06 | $132.09 | $368.78 |