- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.03 / $203.03 / $215.86
| Professional | | $203.03 | $203.03 | $215.86 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $233.35 / $233.35 / $233.35
| Facility | 26 | $233.35 | $233.35 | $233.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $237.48 / $259.44 / $595.48
| Professional | | $237.48 | $259.44 | $595.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $237.48 / $260.82 / $595.48
| Professional | | $237.48 | $260.82 | $595.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.34 / $246.65 / $407.92
| Professional | | $181.34 | $246.65 | $407.92 |