- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.91 / $225.54 / $225.54
| Professional | | $122.91 | $225.54 | $225.54 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $344.68 / $344.68 / $344.68
| Facility | 26 | $344.68 | $344.68 | $344.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.44 / $198.50 / $507.98
| Professional | | $173.44 | $198.50 | $507.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.06 / $293.43 / $507.98
| Professional | | $174.06 | $293.43 | $507.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.06 / $293.43 / $507.98
| Professional | | $174.06 | $293.43 | $507.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.44 / $277.43 / $620.48
| Professional | | $132.44 | $277.43 | $620.48 |