- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $209.05 / $242.33 / $256.43
| Professional | | $209.05 | $242.33 | $256.43 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $337.32 / $337.32 / $337.32
| Facility | 26 | $337.32 | $337.32 | $337.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $205.50 / $242.25 / $603.08
| Professional | | $205.50 | $242.25 | $603.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $210.05 / $340.12 / $603.08
| Professional | | $210.05 | $340.12 | $603.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $210.05 / $340.12 / $603.08
| Professional | | $210.05 | $340.12 | $603.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.72 / $329.37 / $641.52
| Professional | | $168.72 | $329.37 | $641.52 |