- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $105.89 / $105.89 / $105.89
| Facility | 26 | $105.89 | $105.89 | $105.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $175.19 / $238.42 / $354.32
| Professional | | $175.19 | $238.42 | $354.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.02 / $263.02 / $263.02
| Professional | | $263.02 | $263.02 | $263.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $189.33 / $259.35 / $306.02
| Professional | | $189.33 | $259.35 | $306.02 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $90.16 / $90.16 / $90.16
| Facility | 26 | $90.16 | $90.16 | $90.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $197.74 / $292.00 / $772.79
| Professional | | $197.74 | $292.00 | $772.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.46 / $240.74 / $306.08
| Professional | | $172.46 | $240.74 | $306.08 |