- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $270.02 / $364.30 / $1,761.20
| Professional | | $270.02 | $364.30 | $1,761.20 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $184.56 / $184.56 / $228.15
| Facility | 26 | $184.56 | $184.56 | $228.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $481.00 / $755.05 / $1,205.68
| Professional | | $481.00 | $755.05 | $1,205.68 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $184.56 / $184.56 / $228.15
| Facility | 26 | $184.56 | $184.56 | $228.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $483.96 / $806.64 / $1,231.85
| Professional | | $483.96 | $806.64 | $1,231.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $397.10 / $463.51 / $957.66
| Professional | | $397.10 | $463.51 | $957.66 |