- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.25 / $186.16 / $190.92
| Professional | | $166.25 | $186.16 | $190.92 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $106.07 / $106.07 / $106.07
| Facility | 26 | $106.07 | $106.07 | $106.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.32 / $172.60 / $587.13
| Professional | | $143.32 | $172.60 | $587.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.79 / $164.61 / $587.13
| Professional | | $88.79 | $164.61 | $587.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.79 / $105.00 / $587.13
| Professional | | $88.79 | $105.00 | $587.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.10 / $135.19 / $497.03
| Professional | | $95.10 | $135.19 | $497.03 |