- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $59.67 / $67.12 / $379.00
| Professional | | $59.67 | $67.12 | $379.00 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $166.56 / $166.56 / $166.56
| Facility | 26 | $166.56 | $166.56 | $166.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.28 / $93.28 / $109.95
| Professional | | $93.28 | $93.28 | $109.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.67 / $105.14 / $297.01
| Professional | | $93.67 | $105.14 | $297.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.97 / $104.22 / $297.01
| Professional | | $84.97 | $104.22 | $297.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.15 / $96.09 / $171.92
| Professional | | $70.15 | $96.09 | $171.92 |