- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $138.04 / $295.12
| Professional | | $107.15 | $138.04 | $295.12 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $316.23 / $316.23 / $316.23
| Facility | 26 | $316.23 | $316.23 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $162.18 / $380.19
| Professional | | $162.18 | $162.18 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $251.19 / $660.69
| Professional | | $158.49 | $251.19 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $147.91 / $660.69
| Professional | | $141.25 | $147.91 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $162.18 / $371.54
| Professional | | $125.89 | $162.18 | $371.54 |