- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $61.66 / $61.66 / $61.66
| Facility | 26 | $61.66 | $61.66 | $61.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.50 / $151.36 / $295.12
| Professional | | $95.50 | $151.36 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $190.55 / $478.63
| Professional | | $125.89 | $190.55 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $33.11 / $346.74
| Professional | | $32.36 | $33.11 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $5,248.07 / $5,248.07 / $5,248.07
| Facility | 26 | $5,248.07 | $5,248.07 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $208.93 / $309.03
| Professional | | $158.49 | $208.93 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $177.83 / $269.15
| Professional | | $104.71 | $177.83 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.86 / $107.15 / $269.15
| Professional | | $75.86 | $107.15 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $151.36 / $363.08
| Professional | | $120.23 | $151.36 | $363.08 |