- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.09 / $223.22 / $1,090.57
| Professional | | $167.09 | $223.22 | $1,090.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.56 / $72.56 / $296.55
| Professional | | $72.56 | $72.56 | $296.55 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $72.56 / $72.56 / $86.25
| Facility | 26 | $72.56 | $72.56 | $86.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $258.20 / $296.55 / $445.56
| Professional | | $258.20 | $296.55 | $445.56 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $72.56 / $72.56 / $86.25
| Facility | 26 | $72.56 | $72.56 | $86.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $185.04 / $333.47 / $461.92
| Professional | | $185.04 | $333.47 | $461.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $290.19 / $340.47 / $403.84
| Professional | | $290.19 | $340.47 | $403.84 |