- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.74 / $360.99 / $2,731.34
| Professional | | $300.74 | $360.99 | $2,731.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.86 / $88.86 / $695.63
| Professional | | $88.86 | $88.86 | $695.63 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $88.86 / $88.86 / $109.85
| Facility | 26 | $88.86 | $88.86 | $109.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.98 / $429.92 / $696.07
| Professional | | $295.98 | $429.92 | $696.07 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $88.86 / $88.86 / $109.85
| Facility | 26 | $88.86 | $88.86 | $109.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $425.73 / $603.12 / $812.42
| Professional | | $425.73 | $603.12 | $812.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $397.30 / $593.23 / $833.45
| Professional | | $397.30 | $593.23 | $833.45 |