- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.18 / $100.00 / $199.53
| Professional | | $83.18 | $100.00 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.90 / $134.90 / $134.90
| Professional | | $134.90 | $134.90 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.28 / $114.82 / $134.90
| Professional | | $81.28 | $114.82 | $134.90 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $12.59 / $58.88 / $83.18
| Facility | 26 | $12.59 | $58.88 | $83.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.18 / $109.65 / $199.53
| Professional | | $83.18 | $109.65 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.18 / $95.50 / $151.36
| Professional | | $69.18 | $95.50 | $151.36 |