- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $64.73 / $64.73 / $64.73
| Facility | 26 | $64.73 | $64.73 | $64.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.52 / $192.40 / $255.87
| Professional | | $105.52 | $192.40 | $255.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.05 / $229.43 / $487.40
| Professional | | $146.05 | $229.43 | $487.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.57 / $67.28 / $135.78
| Professional | | $32.57 | $67.28 | $135.78 |
- 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
- $186.39 / $217.52 / $294.44
| Professional | | $186.39 | $217.52 | $294.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.38 / $186.53 / $332.02
| Professional | | $140.38 | $186.53 | $332.02 |