- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $98.57 / $98.57 / $98.57
| Facility | 26 | $98.57 | $98.57 | $98.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $233.65 / $257.01 / $550.72
| Professional | | $233.65 | $257.01 | $550.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $628.66 / $768.72 / $960.90
| Professional | | $628.66 | $768.72 | $960.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $272.29 / $495.08 / $599.64
| Professional | | $272.29 | $495.08 | $599.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $475.67 / $599.64 / $810.54
| Professional | | $475.67 | $599.64 | $810.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $325.32 / $483.48 / $633.32
| Professional | | $325.32 | $483.48 | $633.32 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $114.13 / $160.02 / $188.25
| Professional | 26 | $114.13 | $160.02 | $188.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $297.05 / $495.08 / $921.08
| Professional | | $297.05 | $495.08 | $921.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $603.29 / $709.80 / $709.80
| Professional | | $603.29 | $709.80 | $709.80 |