- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $291.72 / $475.00 / $1,803.93
| Professional | | $291.72 | $475.00 | $1,803.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $171.41 / $171.41 / $451.14
| Professional | | $171.41 | $171.41 | $451.14 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $171.41 / $171.41 / $211.90
| Facility | 26 | $171.41 | $171.41 | $211.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $415.93 / $546.75 / $739.45
| Professional | | $415.93 | $546.75 | $739.45 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $171.41 / $171.41 / $211.90
| Facility | 26 | $171.41 | $171.41 | $211.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $287.62 / $476.11 / $728.22
| Professional | | $287.62 | $476.11 | $728.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $276.39 / $385.51 / $571.05
| Professional | | $276.39 | $385.51 | $571.05 |