- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.87 / $164.73 / $691.00
| Professional | | $119.87 | $164.73 | $691.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.75 / $96.75 / $272.89
| Professional | | $96.75 | $96.75 | $272.89 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $96.75 / $96.75 / $119.60
| Facility | 26 | $96.75 | $96.75 | $119.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.71 / $226.40 / $310.27
| Professional | | $125.71 | $226.40 | $310.27 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $96.75 / $96.75 / $119.60
| Facility | 26 | $96.75 | $96.75 | $119.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.97 / $269.37 / $393.54
| Professional | | $165.97 | $269.37 | $393.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.00 / $145.80 / $256.05
| Professional | | $125.00 | $145.80 | $256.05 |