- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.31 / $194.31 / $194.31
| Professional | | $194.31 | $194.31 | $194.31 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $128.33 / $128.33 / $128.33
| Facility | 26 | $128.33 | $128.33 | $128.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $210.22 / $210.22 / $762.36
| Professional | | $210.22 | $210.22 | $762.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $205.13 / $269.77 / $762.36
| Professional | | $205.13 | $269.77 | $762.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $205.13 / $269.77 / $762.36
| Professional | | $205.13 | $269.77 | $762.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.30 / $252.64 / $524.67
| Professional | | $159.30 | $252.64 | $524.67 |