- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.21 / $126.37 / $615.42
| Professional | | $94.21 | $126.37 | $615.42 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $205.85 / $205.85 / $205.85
| Facility | 26 | $205.85 | $205.85 | $205.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.91 / $166.12 / $498.59
| Professional | | $140.91 | $166.12 | $498.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.12 / $166.94 / $498.59
| Professional | | $150.12 | $166.94 | $498.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.77 / $165.73 / $498.59
| Professional | | $125.77 | $165.73 | $498.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.79 / $145.69 / $272.30
| Professional | | $117.79 | $145.69 | $272.30 |