- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.84 / $223.23 / $223.23
| Professional | | $127.84 | $223.23 | $223.23 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $343.63 / $343.63 / $343.63
| Facility | 26 | $343.63 | $343.63 | $343.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.35 / $311.27 / $532.94
| Professional | | $183.35 | $311.27 | $532.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.35 / $311.27 / $532.94
| Professional | | $183.35 | $311.27 | $532.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.44 / $291.06 / $618.14
| Professional | | $142.44 | $291.06 | $618.14 |