- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $204.17 / $251.19
| Professional | | $204.17 | $204.17 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $35.48 / $36.31 / $44.67
| Professional | 26 | $35.48 | $36.31 | $44.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.62 / $120.23 / $1,148.15
| Professional | | $77.62 | $120.23 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $31.62 / $57.54 / $194.98
| Professional | 26 | $31.62 | $57.54 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.61 / $109.65 / $239.88
| Professional | | $67.61 | $109.65 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $30.90 / $54.95 / $75.86
| Professional | 26 | $30.90 | $54.95 | $75.86 |