- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.96 / $134.72 / $248.63
| Professional | | $92.96 | $134.72 | $248.63 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $20.65 / $46.79 / $51.90
| Professional | 26 | $20.65 | $46.79 | $51.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.85 / $172.85 / $172.85
| Professional | | $172.85 | $172.85 | $172.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $49.91 / $89.84 / $199.65
| Professional | | $49.91 | $89.84 | $199.65 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $12.39 / $29.40 / $53.46
| Professional | 26 | $12.39 | $29.40 | $53.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $32.34
| Professional | | $32.34 | $32.34 | $32.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.53 / $125.05 / $264.00
| Professional | | $57.53 | $125.05 | $264.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $16.36 / $30.97 / $77.22
| Professional | 26 | $16.36 | $30.97 | $77.22 |