- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $195.72 / $195.72 / $208.64
| Professional | | $195.72 | $195.72 | $208.64 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $192.02 / $192.02 / $192.02
| Facility | 26 | $192.02 | $192.02 | $192.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $283.63 / $283.63 / $1,002.68
| Professional | | $283.63 | $283.63 | $1,002.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $238.69 / $333.38 / $1,002.68
| Professional | | $238.69 | $333.38 | $1,002.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $238.69 / $275.70 / $1,002.68
| Professional | | $238.69 | $275.70 | $1,002.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.89 / $292.43 / $547.61
| Professional | | $168.89 | $292.43 | $547.61 |