- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $297.27 / $400.84 / $1,802.33
| Professional | | $297.27 | $400.84 | $1,802.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.31 / $118.31 / $514.23
| Professional | | $118.31 | $118.31 | $514.23 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $118.31 / $118.31 / $146.25
| Facility | 26 | $118.31 | $118.31 | $146.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $393.83 / $589.76 / $880.50
| Professional | | $393.83 | $589.76 | $880.50 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $118.31 / $118.31 / $146.25
| Facility | 26 | $118.31 | $118.31 | $146.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $352.95 / $542.97 / $835.49
| Professional | | $352.95 | $542.97 | $835.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $320.88 / $443.17 / $662.96
| Professional | | $320.88 | $443.17 | $662.96 |