- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.00 / $63.09 / $65.41
| Professional | | $56.00 | $63.09 | $65.41 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $159.13 / $159.13 / $159.13
| Facility | 26 | $159.13 | $159.13 | $159.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.75 / $80.75 / $254.25
| Professional | | $80.75 | $80.75 | $254.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.70 / $87.24 / $254.25
| Professional | | $74.70 | $87.24 | $254.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.70 / $87.24 / $254.25
| Professional | | $74.70 | $87.24 | $254.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.18 / $91.26 / $270.45
| Professional | | $61.18 | $91.26 | $270.45 |