- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.72 / $106.79 / $570.83
| Professional | | $83.72 | $106.79 | $570.83 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $213.24 / $213.24 / $213.24
| Facility | 26 | $213.24 | $213.24 | $213.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.18 / $135.18 / $408.74
| Professional | | $135.18 | $135.18 | $408.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.62 / $146.81 / $408.74
| Professional | | $97.62 | $146.81 | $408.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.31 / $145.71 / $408.74
| Professional | | $112.31 | $145.71 | $408.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.38 / $140.52 / $434.79
| Professional | | $102.38 | $140.52 | $434.79 |