- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.25 / $117.25 / $763.99
| Professional | | $117.25 | $117.25 | $763.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $564.54 / $564.54 / $763.99
| Professional | | $564.54 | $564.54 | $763.99 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $117.25 / $117.25 / $126.88
| Professional | 26 | $117.25 | $117.25 | $126.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $469.32 / $613.66 / $763.99
| Professional | | $469.32 | $613.66 | $763.99 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $117.25 / $117.25 / $126.88
| Professional | 26 | $117.25 | $117.25 | $126.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $209.24 / $236.46 / $433.51
| Professional | | $209.24 | $236.46 | $433.51 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $47.48 / $47.86 / $87.74
| Professional | 26 | $47.48 | $47.86 | $87.74 |