- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.50 / $156.85 / $917.00
| Professional | | $133.50 | $156.85 | $917.00 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $511.41 / $511.41 / $511.41
| Facility | 26 | $511.41 | $511.41 | $511.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $228.52 / $269.38 / $818.66
| Professional | | $228.52 | $269.38 | $818.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $249.55 / $286.20 / $818.66
| Professional | | $249.55 | $286.20 | $818.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $212.49 / $281.20 / $818.66
| Professional | | $212.49 | $281.20 | $818.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $195.80 / $232.69 / $447.11
| Professional | | $195.80 | $232.69 | $447.11 |