- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $102.87 / $102.87 / $102.87
| Facility | 26 | $102.87 | $102.87 | $102.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $375.44 / $455.18 / $493.48
| Professional | | $375.44 | $455.18 | $493.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.55 / $236.27 / $550.77
| Professional | | $88.55 | $236.27 | $550.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.01 / $352.71 / $507.83
| Professional | | $174.01 | $352.71 | $507.83 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $344.40 / $419.33 / $419.33
| Facility | 26 | $344.40 | $419.33 | $419.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $261.25 / $403.19 / $3,193.76
| Professional | | $261.25 | $403.19 | $3,193.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $252.00 / $345.59 / $612.79
| Professional | | $252.00 | $345.59 | $612.79 |