- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.22 / $223.62 / $337.86
| Professional | | $146.22 | $223.62 | $337.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.53 / $226.90 / $283.62
| Professional | | $198.53 | $226.90 | $283.62 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $52.38 / $52.38 / $52.38
| Facility | 26 | $52.38 | $52.38 | $52.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.04 / $270.38 / $481.06
| Professional | | $177.04 | $270.38 | $481.06 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $233.70 / $233.70 / $233.70
| Facility | 26 | $233.70 | $233.70 | $233.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $201.92 / $258.70 / $1,494.48
| Professional | | $201.92 | $258.70 | $1,494.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $195.08 / $240.90 / $379.59
| Professional | | $195.08 | $240.90 | $379.59 |