- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $427.14 / $427.14 / $454.53
| Professional | | $427.14 | $427.14 | $454.53 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $457.21 / $457.21 / $457.21
| Facility | 26 | $457.21 | $457.21 | $457.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.82 / $721.47 / $2,256.69
| Professional | | $501.82 | $721.47 | $2,256.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.82 / $721.47 / $2,256.69
| Professional | | $501.82 | $721.47 | $2,256.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $342.66 / $613.89 / $1,232.48
| Professional | | $342.66 | $613.89 | $1,232.48 |