- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $342.62 / $342.62 / $366.78
| Professional | | $342.62 | $342.62 | $366.78 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $249.29 / $249.29 / $249.29
| Facility | 26 | $249.29 | $249.29 | $249.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $376.45 / $376.45 / $1,230.02
| Professional | | $376.45 | $376.45 | $1,230.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $402.78 / $456.50 / $1,230.02
| Professional | | $402.78 | $456.50 | $1,230.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $402.78 / $456.50 / $1,230.02
| Professional | | $402.78 | $456.50 | $1,230.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $296.24 / $416.18 / $671.77
| Professional | | $296.24 | $416.18 | $671.77 |