- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $63.10 / $125.89 / $177.83
| Facility | 26 | $63.10 | $125.89 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $416.87 / $630.96
| Professional | | $338.84 | $416.87 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.33 / $93.33 / $537.03
| Professional | | $93.33 | $93.33 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $407.38 / $758.58
| Professional | | $275.42 | $407.38 | $758.58 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $131.83 / $131.83 / $131.83
| Facility | 26 | $131.83 | $131.83 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $512.86 / $3,548.13
| Professional | | $331.13 | $512.86 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $457.09 / $758.58
| Professional | | $309.03 | $457.09 | $758.58 |