- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.47 / $320.67 / $1,864.00
| Professional | | $286.47 | $320.67 | $1,864.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.23 / $86.23 / $510.55
| Professional | | $86.23 | $86.23 | $510.55 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $86.23 / $86.23 / $106.60
| Facility | 26 | $86.23 | $86.23 | $106.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.11 / $510.55 / $993.27
| Professional | | $248.11 | $510.55 | $993.27 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $86.23 / $86.23 / $106.60
| Facility | 26 | $86.23 | $86.23 | $106.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.13 / $459.22 / $620.63
| Professional | | $316.13 | $459.22 | $620.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $280.51 / $315.60 / $643.30
| Professional | | $280.51 | $315.60 | $643.30 |