- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $368.22 / $486.46 / $992.83
| Professional | | $368.22 | $486.46 | $992.83 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $144.60 / $144.60 / $144.60
| Facility | 26 | $144.60 | $144.60 | $144.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.91 / $415.55 / $1,681.88
| Professional | | $234.91 | $415.55 | $1,681.88 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $144.60 / $144.60 / $144.60
| Facility | 26 | $144.60 | $144.60 | $144.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $415.55 / $667.15 / $1,099.46
| Professional | | $415.55 | $667.15 | $1,099.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $350.42 / $585.19 / $767.98
| Professional | | $350.42 | $585.19 | $767.98 |