- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $980.03 / $1,034.55 / $2,769.42
| Professional | | $980.03 | $1,034.55 | $2,769.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,157.41 / $1,206.08 / $1,531.73
| Professional | | $1,157.41 | $1,206.08 | $1,531.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $970.56 / $1,526.13 / $2,728.50
| Professional | | $970.56 | $1,526.13 | $2,728.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,003.83 / $1,294.94 / $2,352.67
| Professional | | $1,003.83 | $1,294.94 | $2,352.67 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $281.04 / $362.54 / $604.16
| Professional | 26 | $281.04 | $362.54 | $604.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $928.50 / $1,168.00 / $2,130.90
| Professional | | $928.50 | $1,168.00 | $2,130.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $860.78 / $860.78 / $1,419.00
| Professional | | $860.78 | $860.78 | $1,419.00 |