- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,148.15 / $2,041.74
| Professional | | $954.99 | $1,148.15 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,148.15 / $1,412.54
| Professional | | $1,047.13 | $1,148.15 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,445.44 / $2,691.53
| Professional | | $933.25 | $1,445.44 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,174.90 / $2,137.96
| Professional | | $1,047.13 | $1,174.90 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $281.84 / $323.59 / $575.44
| Professional | 26 | $281.84 | $323.59 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,230.27 / $2,137.96
| Professional | | $851.14 | $1,230.27 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,202.26 / $1,659.59
| Professional | | $851.14 | $1,202.26 | $1,659.59 |