- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $334.05 / $334.05 / $357.48
| Professional | | $334.05 | $334.05 | $357.48 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $249.29 / $249.29 / $249.29
| Facility | 26 | $249.29 | $249.29 | $249.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $378.10 / $378.10 / $1,238.60
| Professional | | $378.10 | $378.10 | $1,238.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $395.56 / $443.66 / $1,238.60
| Professional | | $395.56 | $443.66 | $1,238.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $395.56 / $443.66 / $1,238.60
| Professional | | $395.56 | $443.66 | $1,238.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $289.52 / $420.24 / $861.94
| Professional | | $289.52 | $420.24 | $861.94 |