- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $175.87 / $175.87 / $188.01
| Professional | | $175.87 | $175.87 | $188.01 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $142.19 / $142.19 / $142.19
| Facility | 26 | $142.19 | $142.19 | $142.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.82 / $325.44 / $988.22
| Professional | | $192.82 | $325.44 | $988.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.82 / $325.44 / $988.22
| Professional | | $192.82 | $325.44 | $988.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.68 / $267.38 / $1,051.20
| Professional | | $153.68 | $267.38 | $1,051.20 |