- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.08 / $121.48 / $663.95
| Professional | | $95.08 | $121.48 | $663.95 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $301.37 / $301.37 / $301.37
| Facility | 26 | $301.37 | $301.37 | $301.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.13 / $174.62 / $496.77
| Professional | | $148.13 | $174.62 | $496.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.50 / $173.68 / $496.77
| Professional | | $157.50 | $173.68 | $496.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.07 / $169.55 / $496.77
| Professional | | $144.07 | $169.55 | $496.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.72 / $154.52 / $271.31
| Professional | | $118.72 | $154.52 | $271.31 |