- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $201.27 / $201.27 / $201.27
| Professional | | $201.27 | $201.27 | $201.27 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $142.19 / $142.19 / $142.19
| Facility | 26 | $142.19 | $142.19 | $142.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $220.31 / $220.31 / $785.24
| Professional | | $220.31 | $220.31 | $785.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $228.26 / $275.45 / $785.24
| Professional | | $228.26 | $275.45 | $785.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $228.26 / $275.45 / $785.24
| Professional | | $228.26 | $275.45 | $785.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.17 / $260.13 / $428.86
| Professional | | $170.17 | $260.13 | $428.86 |