- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $114.24 / $114.24 / $114.24
| Facility | 26 | $114.24 | $114.24 | $114.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $274.94 / $327.37 / $562.74
| Professional | | $274.94 | $327.37 | $562.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $382.34 / $465.45 / $804.87
| Professional | | $382.34 | $465.45 | $804.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $305.37 / $695.80 / $1,012.53
| Professional | | $305.37 | $695.80 | $1,012.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $414.14 / $511.58 / $864.77
| Professional | | $414.14 | $511.58 | $864.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.38 / $327.37 / $700.21
| Professional | | $263.38 | $327.37 | $700.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $345.09 / $431.36 / $888.05
| Professional | | $345.09 | $431.36 | $888.05 |