- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.63 / $148.63 / $151.16
| Professional | | $148.63 | $148.63 | $151.16 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $518.80 / $518.80 / $518.80
| Facility | 26 | $518.80 | $518.80 | $518.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.33 / $184.33 / $569.49
| Professional | | $184.33 | $184.33 | $569.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $189.64 / $210.41 / $569.49
| Professional | | $189.64 | $210.41 | $569.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $189.64 / $210.41 / $569.49
| Professional | | $189.64 | $210.41 | $569.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.77 / $230.81 / $605.79
| Professional | | $143.77 | $230.81 | $605.79 |