- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $980.03 / $1,034.55 / $1,606.90
| Professional | | $980.03 | $1,034.55 | $1,606.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.42 / $426.42 / $1,566.88
| Professional | | $426.42 | $426.42 | $1,566.88 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $426.42 / $426.42 / $506.88
| Facility | 26 | $426.42 | $426.42 | $506.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,104.06 / $1,566.36 / $2,344.50
| Professional | | $1,104.06 | $1,566.36 | $2,344.50 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $426.42 / $426.42 / $506.88
| Facility | 26 | $426.42 | $426.42 | $506.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,007.70 / $1,427.60 / $2,234.19
| Professional | | $1,007.70 | $1,427.60 | $2,234.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,531.01 / $1,741.08 / $2,065.69
| Professional | | $1,531.01 | $1,741.08 | $2,065.69 |