- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $375.00 / $425.00 / $425.00
| Professional | | $375.00 | $425.00 | $425.00 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $469.88 / $469.88 / $469.88
| Facility | 26 | $469.88 | $469.88 | $469.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $577.87 / $681.18 / $1,417.85
| Professional | | $577.87 | $681.18 | $1,417.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $481.96 / $748.56 / $1,417.85
| Professional | | $481.96 | $748.56 | $1,417.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $481.96 / $734.40 / $1,417.85
| Professional | | $481.96 | $734.40 | $1,417.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $377.50 / $734.17 / $1,508.22
| Professional | | $377.50 | $734.17 | $1,508.22 |