- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $73.83 / $102.06 / $209.84
| Facility | 26 | $73.83 | $102.06 | $209.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $216.41 / $243.99 / $361.64
| Professional | | $216.41 | $243.99 | $361.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.86 / $246.11 / $452.64
| Professional | | $181.86 | $246.11 | $452.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.83 / $293.92 / $487.74
| Professional | | $206.83 | $293.92 | $487.74 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $174.23 / $363.28 / $363.28
| Facility | 26 | $174.23 | $363.28 | $363.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,687.36 / $1,690.06 / $1,741.05
| Professional | | $1,687.36 | $1,690.06 | $1,741.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.04 / $305.43 / $483.33
| Professional | | $199.04 | $305.43 | $483.33 |