- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.84 / $88.18 / $411.00
| Professional | | $71.84 | $88.18 | $411.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.39 / $28.39 / $147.75
| Professional | | $28.39 | $28.39 | $147.75 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $28.39 / $28.39 / $35.10
| Facility | 26 | $28.39 | $28.39 | $35.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.91 / $117.49 / $193.23
| Professional | | $72.91 | $117.49 | $193.23 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $28.39 / $28.39 / $35.10
| Facility | 26 | $28.39 | $28.39 | $35.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.11 / $147.75 / $241.34
| Professional | | $95.11 | $147.75 | $241.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $76.33 / $91.67 / $160.99
| Professional | | $76.33 | $91.67 | $160.99 |