- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.63 / $216.00 / $1,402.11
| Professional | | $192.63 | $216.00 | $1,402.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.63 / $53.63 / $341.77
| Professional | | $53.63 | $53.63 | $341.77 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $53.63 / $53.63 / $66.30
| Facility | 26 | $53.63 | $53.63 | $66.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.58 / $341.77 / $665.13
| Professional | | $177.58 | $341.77 | $665.13 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $53.63 / $53.63 / $66.30
| Facility | 26 | $53.63 | $53.63 | $66.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.80 / $307.06 / $416.27
| Professional | | $211.80 | $307.06 | $416.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $171.44 / $212.42 / $429.09
| Professional | | $171.44 | $212.42 | $429.09 |