- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $222.70 / $222.70 / $237.41
| Professional | | $222.70 | $222.70 | $237.41 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $216.41 / $216.41 / $216.41
| Facility | 26 | $216.41 | $216.41 | $216.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.81 / $263.81 / $941.26
| Professional | | $263.81 | $263.81 | $941.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.13 / $337.29 / $941.26
| Professional | | $263.13 | $337.29 | $941.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.13 / $337.29 / $941.26
| Professional | | $263.13 | $337.29 | $941.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.49 / $301.50 / $514.05
| Professional | | $192.49 | $301.50 | $514.05 |