- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $478.63 / $602.56
| Professional | | $323.59 | $478.63 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $467.74 / $467.74 / $467.74
| Facility | 26 | $467.74 | $467.74 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $575.44 / $1,412.54
| Professional | | $575.44 | $575.44 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $741.31 / $1,412.54
| Professional | | $436.52 | $741.31 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $398.11 / $1,412.54
| Professional | | $398.11 | $398.11 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $724.44 / $1,122.02
| Professional | | $363.08 | $724.44 | $1,122.02 |