- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.33 / $187.65 / $187.65
| Professional | | $104.33 | $187.65 | $187.65 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $155.97 / $155.97 / $155.97
| Facility | 26 | $155.97 | $155.97 | $155.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.91 / $186.16 / $440.80
| Professional | | $157.91 | $186.16 | $440.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.66 / $261.13 / $440.80
| Professional | | $153.66 | $261.13 | $440.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.66 / $261.13 / $440.80
| Professional | | $153.66 | $261.13 | $440.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.49 / $240.74 / $572.49
| Professional | | $119.49 | $240.74 | $572.49 |