- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $147.91 / $269.15
| Professional | | $104.71 | $147.91 | $269.15 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $512.86 / $512.86 / $512.86
| Facility | 26 | $512.86 | $512.86 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $186.21 / $575.44
| Professional | | $186.21 | $186.21 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $208.93 / $575.44
| Professional | | $186.21 | $208.93 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $575.44 / $575.44
| Professional | | $575.44 | $575.44 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $229.09 / $602.56
| Professional | | $144.54 | $229.09 | $602.56 |