- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $357.64 / $503.86 / $503.86
| Professional | | $357.64 | $503.86 | $503.86 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $702.40 / $702.40 / $702.40
| Facility | 26 | $702.40 | $702.40 | $702.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $635.41 / $724.64 / $2,091.67
| Professional | | $635.41 | $724.64 | $2,091.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $604.84 / $724.64 / $2,091.67
| Professional | | $604.84 | $724.64 | $2,091.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $530.54 / $703.88 / $2,051.10
| Professional | | $530.54 | $703.88 | $2,051.10 |