- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.42 / $139.91 / $726.00
| Professional | | $108.42 | $139.91 | $726.00 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $317.26 / $317.26 / $317.26
| Facility | 26 | $317.26 | $317.26 | $317.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.38 / $190.23 / $659.85
| Professional | | $161.38 | $190.23 | $659.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.31 / $253.08 / $659.85
| Professional | | $168.31 | $253.08 | $659.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.13 / $199.27 / $659.85
| Professional | | $154.13 | $199.27 | $659.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.93 / $169.21 / $360.38
| Professional | | $120.93 | $169.21 | $360.38 |