- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $347.43 / $347.43 / $347.43
| Professional | | $347.43 | $347.43 | $347.43 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $309.70 / $309.70 / $309.70
| Facility | 26 | $309.70 | $309.70 | $309.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,884.59 / $1,884.59 / $1,884.59
| Professional | | $1,884.59 | $1,884.59 | $1,884.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $428.27 / $638.70 / $1,884.59
| Professional | | $428.27 | $638.70 | $1,884.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $428.27 / $638.70 / $1,884.59
| Professional | | $428.27 | $638.70 | $1,884.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $312.52 / $475.47 / $2,004.71
| Professional | | $312.52 | $475.47 | $2,004.71 |