- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $272.94 / $420.00 / $1,453.74
| Professional | | $272.94 | $420.00 | $1,453.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.36 / $119.36 / $426.95
| Professional | | $119.36 | $119.36 | $426.95 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $119.36 / $119.36 / $147.55
| Facility | 26 | $119.36 | $119.36 | $147.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.95 / $634.48 / $827.63
| Professional | | $426.95 | $634.48 | $827.63 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $119.36 / $119.36 / $147.55
| Facility | 26 | $119.36 | $119.36 | $147.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $290.92 / $466.01 / $703.60
| Professional | | $290.92 | $466.01 | $703.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.20 / $471.07 / $760.34
| Professional | | $263.20 | $471.07 | $760.34 |