- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.44 / $211.07 / $281.97
| Professional | | $165.44 | $211.07 | $281.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $253.11 / $325.38 / $485.80
| Professional | | $253.11 | $325.38 | $485.80 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $113.41 / $113.41 / $113.41
| Facility | 26 | $113.41 | $113.41 | $113.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $237.65 / $343.50 / $583.63
| Professional | | $237.65 | $343.50 | $583.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.45 / $371.51 / $569.91
| Professional | | $288.45 | $371.51 | $569.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.44 / $281.97 / $455.31
| Professional | | $165.44 | $281.97 | $455.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.19 / $282.20 / $520.73
| Professional | | $206.19 | $282.20 | $520.73 |