- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.34 / $333.91 / $1,933.63
| Professional | | $157.34 | $333.91 | $1,933.63 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $93.59 / $93.59 / $111.25
| Facility | 26 | $93.59 | $93.59 | $111.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.14 / $243.28 / $428.53
| Professional | | $71.14 | $243.28 | $428.53 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $93.59 / $93.59 / $111.25
| Facility | 26 | $93.59 | $93.59 | $111.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.28 / $353.40 / $522.53
| Professional | | $243.28 | $353.40 | $522.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.90 / $168.90 / $281.50
| Professional | | $157.90 | $168.90 | $281.50 |