- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $345.08 / $418.76 / $2,269.15
| Professional | | $345.08 | $418.76 | $2,269.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.88 / $119.88 / $537.89
| Professional | | $119.88 | $119.88 | $537.89 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $119.88 / $119.88 / $148.19
| Facility | 26 | $119.88 | $119.88 | $148.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $500.49 / $658.82 / $912.34
| Professional | | $500.49 | $658.82 | $912.34 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $119.88 / $119.88 / $148.19
| Facility | 26 | $119.88 | $119.88 | $148.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $368.73 / $567.24 / $886.43
| Professional | | $368.73 | $567.24 | $886.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $336.82 / $476.09 / $695.90
| Professional | | $336.82 | $476.09 | $695.90 |