- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $64.33 / $64.33 / $64.33
| Facility | 26 | $64.33 | $64.33 | $64.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.47 / $223.58 / $405.42
| Professional | | $101.47 | $223.58 | $405.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.26 / $221.75 / $491.78
| Professional | | $139.26 | $221.75 | $491.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.57 / $67.28 / $102.43
| Professional | | $32.57 | $67.28 | $102.43 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $8,682.07 / $8,682.07 / $8,682.07
| Facility | 26 | $8,682.07 | $8,682.07 | $8,682.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $179.45 / $224.80 / $297.58
| Professional | | $179.45 | $224.80 | $297.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.44 / $177.20 / $315.62
| Professional | | $132.44 | $177.20 | $315.62 |