- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.96 / $204.17 / $346.74
| Professional | | $165.96 | $204.17 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.28 / $81.28 / $302.00
| Professional | | $81.28 | $81.28 | $302.00 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $81.28 / $81.28 / $97.72
| Facility | 26 | $81.28 | $81.28 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $234.42 / $512.86
| Professional | | $138.04 | $234.42 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $331.13 / $354.81
| Professional | | $316.23 | $331.13 | $354.81 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $81.28 / $81.28 / $97.72
| Facility | 26 | $81.28 | $81.28 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $416.87 / $549.54
| Professional | | $199.53 | $416.87 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $331.13 / $407.38
| Professional | | $169.82 | $331.13 | $407.38 |