- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.31 / $102.59 / $108.66
| Professional | | $83.31 | $102.59 | $108.66 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $137.91 / $137.91 / $137.91
| Facility | 26 | $137.91 | $137.91 | $137.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.91 / $136.47 / $349.98
| Professional | | $108.91 | $136.47 | $349.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.91 / $136.47 / $349.98
| Professional | | $108.91 | $136.47 | $349.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.94 / $128.86 / $347.78
| Professional | | $86.94 | $128.86 | $347.78 |