- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $467.74 / $630.96
| Professional | | $346.74 | $467.74 | $630.96 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $309.03 / $309.03 / $309.03
| Facility | 26 | $309.03 | $309.03 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $1,905.46
| Professional | | $1,905.46 | $1,905.46 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $645.65 / $1,905.46
| Professional | | $407.38 | $645.65 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $1,905.46
| Professional | | $1,905.46 | $1,905.46 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $575.44 / $1,819.70
| Professional | | $309.03 | $575.44 | $1,819.70 |