- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.56 / $211.76 / $230.92
| Professional | | $121.56 | $211.76 | $230.92 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $327.86 / $327.86 / $327.86
| Facility | 26 | $327.86 | $327.86 | $327.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $502.40 / $502.40 / $502.40
| Professional | | $502.40 | $502.40 | $502.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.65 / $293.68 / $502.40
| Professional | | $169.65 | $293.68 | $502.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.65 / $293.68 / $502.40
| Professional | | $169.65 | $293.68 | $502.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.49 / $260.14 / $610.17
| Professional | | $146.49 | $260.14 | $610.17 |