- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $78.44 / $78.44 / $78.44
| Facility | 26 | $78.44 | $78.44 | $78.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $246.59 / $288.87 / $661.50
| Professional | | $246.59 | $288.87 | $661.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $511.94 / $625.99 / $782.49
| Professional | | $511.94 | $625.99 | $782.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $368.57 / $568.21 / $3,348.15
| Professional | | $368.57 | $568.21 | $3,348.15 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $255.57 / $255.57 / $255.57
| Facility | 26 | $255.57 | $255.57 | $255.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $568.59 / $689.94 / $1,045.00
| Professional | | $568.59 | $689.94 | $1,045.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $377.98 / $503.97 / $668.95
| Professional | | $377.98 | $503.97 | $668.95 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $99.11 / $129.37 / $147.49
| Professional | 26 | $99.11 | $129.37 | $147.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $324.35 / $568.21 / $815.64
| Professional | | $324.35 | $568.21 | $815.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $594.79 / $699.80 / $699.80
| Professional | | $594.79 | $699.80 | $699.80 |