- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.81 / $240.85 / $367.79
| Professional | | $172.81 | $240.85 | $367.79 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $162.47 / $162.47 / $193.13
| Facility | 26 | $162.47 | $162.47 | $193.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.31 / $328.42 / $962.52
| Professional | | $169.31 | $328.42 | $962.52 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $162.47 / $162.47 / $193.13
| Facility | 26 | $162.47 | $162.47 | $193.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $231.30 / $364.91 / $558.41
| Professional | | $231.30 | $364.91 | $558.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $259.26 / $394.40 / $480.75
| Professional | | $259.26 | $394.40 | $480.75 |