- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $307.81 / $307.81 / $307.81
| Facility | 26 | $307.81 | $307.81 | $307.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.50 / $160.11 / $313.88
| Professional | | $133.50 | $160.11 | $313.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.01 / $264.02 / $365.61
| Professional | | $204.01 | $264.02 | $365.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $178.88 / $286.20 / $431.77
| Professional | | $178.88 | $286.20 | $431.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $233.72 / $270.41 / $414.83
| Professional | | $233.72 | $270.41 | $414.83 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $307.81 / $307.81 / $307.81
| Facility | 26 | $307.81 | $307.81 | $307.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.50 / $225.96 / $359.22
| Professional | | $133.50 | $225.96 | $359.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $189.30 / $285.04 / $392.25
| Professional | | $189.30 | $285.04 | $392.25 |