- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.29 / $215.86 / $1,094.67
| Professional | | $199.29 | $215.86 | $1,094.67 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $55.73 / $55.73 / $68.90
| Facility | 26 | $55.73 | $55.73 | $68.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $273.94 / $532.41
| Professional | | $150.00 | $273.94 | $532.41 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $55.73 / $55.73 / $68.90
| Facility | 26 | $55.73 | $55.73 | $68.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.19 / $245.19 / $330.75
| Professional | | $169.19 | $245.19 | $330.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.77 / $162.58 / $335.90
| Professional | | $159.77 | $162.58 | $335.90 |