- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.84 / $83.28 / $99.50
| Professional | | $71.84 | $83.28 | $99.50 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $111.38 / $111.38 / $111.38
| Facility | 26 | $111.38 | $111.38 | $111.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.44 / $121.83 / $409.84
| Professional | | $101.44 | $121.83 | $409.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.56 / $132.26 / $409.84
| Professional | | $100.56 | $132.26 | $409.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $117.22 / $409.84
| Professional | | $100.00 | $117.22 | $409.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.09 / $118.18 / $435.96
| Professional | | $87.09 | $118.18 | $435.96 |