- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.31 / $17.19 / $31.83
| Professional | | $15.31 | $17.19 | $31.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.04 / $15.28 / $34.21
| Professional | | $11.04 | $15.28 | $34.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.78 / $22.07 / $53.53
| Professional | | $14.78 | $22.07 | $53.53 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $30.82 / $100.00 / $100.00
| Facility | 26 | $30.82 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $221.52 / $261.48 / $268.64
| Professional | | $221.52 | $261.48 | $268.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.90 / $17.47 / $40.38
| Professional | | $12.90 | $17.47 | $40.38 |