- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $62.92 / $62.92 / $62.92
| Facility | 26 | $62.92 | $62.92 | $62.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.27 / $223.26 / $293.68
| Professional | | $100.27 | $223.26 | $293.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.09 / $209.77 / $476.94
| Professional | | $132.09 | $209.77 | $476.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.57 / $67.28 / $106.37
| Professional | | $32.57 | $67.28 | $106.37 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $5,208.22 / $5,208.22 / $5,208.22
| Facility | 26 | $5,208.22 | $5,208.22 | $5,208.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.53 / $211.14 / $286.92
| Professional | | $169.53 | $211.14 | $286.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.12 / $153.74 / $305.30
| Professional | | $128.12 | $153.74 | $305.30 |