- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $489.78 / $645.65
| Professional | | $323.59 | $489.78 | $645.65 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $457.09 / $457.09 / $457.09
| Facility | 26 | $457.09 | $457.09 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $630.96 / $2,238.72
| Professional | | $426.58 | $630.96 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,238.72
| Professional | | $2,238.72 | $2,238.72 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $575.44 / $1,230.27
| Professional | | $338.84 | $575.44 | $1,230.27 |