- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $196.11 / $228.52 / $1,242.00
| Professional | | $196.11 | $228.52 | $1,242.00 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $478.55 / $478.55 / $478.55
| Facility | 26 | $478.55 | $478.55 | $478.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $280.45 / $280.45 / $330.59
| Professional | | $280.45 | $280.45 | $330.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $285.80 / $383.88 / $1,120.33
| Professional | | $285.80 | $383.88 | $1,120.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $277.52 / $381.02 / $1,120.33
| Professional | | $277.52 | $381.02 | $1,120.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $205.35 / $290.58 / $611.86
| Professional | | $205.35 | $290.58 | $611.86 |