- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.62 / $209.87 / $232.81
| Professional | | $97.62 | $209.87 | $232.81 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $42.27 / $94.91 / $105.28
| Professional | 26 | $42.27 | $94.91 | $105.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $241.00 / $241.00 / $241.00
| Professional | | $241.00 | $241.00 | $241.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.36 / $135.80 / $284.08
| Professional | | $57.36 | $135.80 | $284.08 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $24.58 / $60.62 / $136.15
| Professional | 26 | $24.58 | $60.62 | $136.15 |
- 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
- $82.72 / $149.49 / $298.27
| Professional | | $82.72 | $149.49 | $298.27 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $33.72 / $63.52 / $159.88
| Professional | 26 | $33.72 | $63.52 | $159.88 |