- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.58 / $786.64 / $1,389.38
| Professional | | $741.58 | $786.64 | $1,389.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.33 / $200.33 / $1,340.79
| Professional | | $200.33 | $200.33 | $1,340.79 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $200.33 / $200.33 / $238.13
| Facility | 26 | $200.33 | $200.33 | $238.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $825.63 / $1,340.79 / $1,776.96
| Professional | | $825.63 | $1,340.79 | $1,776.96 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $200.33 / $200.33 / $238.13
| Facility | 26 | $200.33 | $200.33 | $238.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $830.26 / $1,237.41 / $1,890.00
| Professional | | $830.26 | $1,237.41 | $1,890.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,145.96 / $1,412.47 / $1,675.81
| Professional | | $1,145.96 | $1,412.47 | $1,675.81 |