- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.43 / $194.01 / $1,435.13
| Professional | | $159.43 | $194.01 | $1,435.13 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $585.66 / $585.66 / $585.66
| Facility | 26 | $585.66 | $585.66 | $585.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $287.70 / $287.70 / $1,093.58
| Professional | | $287.70 | $287.70 | $1,093.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $282.20 / $365.41 / $1,093.58
| Professional | | $282.20 | $365.41 | $1,093.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $207.75 / $324.98 / $1,093.58
| Professional | | $207.75 | $324.98 | $1,093.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $225.74 / $306.48 / $1,163.30
| Professional | | $225.74 | $306.48 | $1,163.30 |