- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $81.28 / $81.28 / $158.49
| Facility | 26 | $81.28 | $81.28 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $302.00 / $758.58
| Professional | | $204.17 | $302.00 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $371.54 / $562.34
| Professional | | $269.15 | $371.54 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $281.84 / $588.84
| Professional | | $181.97 | $281.84 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $457.09 / $2,570.40
| Professional | | $389.05 | $457.09 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $114.82 / $131.83 / $1,348.96
| Professional | 26 | $114.82 | $131.83 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $275.42 / $354.81
| Professional | | $251.19 | $275.42 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $346.74 / $588.84
| Professional | | $208.93 | $346.74 | $588.84 |