- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.29 / $130.29 / $130.29
| Professional | | $130.29 | $130.29 | $130.29 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $46.12 / $46.12 / $46.12
| Professional | 26 | $46.12 | $46.12 | $46.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $175.43 / $267.00 / $421.00
| Professional | | $175.43 | $267.00 | $421.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54.50 / $266.00 / $632.73
| Professional | | $54.50 | $266.00 | $632.73 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $18.10 / $58.98 / $163.02
| Professional | 26 | $18.10 | $58.98 | $163.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.23 / $84.23 / $323.95
| Professional | | $84.23 | $84.23 | $323.95 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $24.25 / $76.58 / $90.95
| Professional | 26 | $24.25 | $76.58 | $90.95 |