- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $39.72 / $39.72 / $39.72
| Facility | 26 | $39.72 | $39.72 | $39.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $256.58 / $324.99 / $477.41
| Professional | | $256.58 | $324.99 | $477.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $540.49 / $660.90 / $826.12
| Professional | | $540.49 | $660.90 | $826.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $274.86 / $425.67 / $708.27
| Professional | | $274.86 | $425.67 | $708.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $455.00 / $630.48 / $840.58
| Professional | | $455.00 | $630.48 | $840.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $341.70 / $475.48 / $551.49
| Professional | | $341.70 | $475.48 | $551.49 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $50.20 / $65.25 / $74.39
| Professional | 26 | $50.20 | $65.25 | $74.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $340.33 / $392.40 / $654.00
| Professional | | $340.33 | $392.40 | $654.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.50 / $562.90 / $562.90
| Professional | | $478.50 | $562.90 | $562.90 |