- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $196.00 / $307.17 / $1,156.81
| Professional | | $196.00 | $307.17 | $1,156.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.22 / $35.22 / $287.08
| Professional | | $35.22 | $35.22 | $287.08 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $35.22 / $35.22 / $43.55
| Facility | 26 | $35.22 | $35.22 | $43.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.46 / $287.08 / $559.25
| Professional | | $148.46 | $287.08 | $559.25 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $35.22 / $35.22 / $43.55
| Facility | 26 | $35.22 | $35.22 | $43.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $178.35 / $255.27 / $347.10
| Professional | | $178.35 | $255.27 | $347.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.26 / $172.56 / $354.29
| Professional | | $153.26 | $172.56 | $354.29 |