- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.79 / $162.55 / $697.51
| Professional | | $121.79 | $162.55 | $697.51 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $347.96 / $347.96 / $347.96
| Facility | 26 | $347.96 | $347.96 | $347.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.24 / $166.18 / $477.74
| Professional | | $85.24 | $166.18 | $477.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.27 / $166.44 / $477.74
| Professional | | $161.27 | $166.44 | $477.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.51 / $221.26 / $508.19
| Professional | | $125.51 | $221.26 | $508.19 |