- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $52.54 / $107.10 / $107.10
| Facility | 26 | $52.54 | $107.10 | $107.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.25 / $353.52 / $414.55
| Professional | | $338.25 | $353.52 | $414.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $558.67 / $558.67 / $558.67
| Professional | | $558.67 | $558.67 | $558.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.39 / $528.16 / $706.79
| Professional | | $302.39 | $528.16 | $706.79 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $107.73 / $107.73 / $204.38
| Facility | 26 | $107.73 | $107.73 | $204.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $405.75 / $502.01 / $2,395.01
| Professional | | $405.75 | $502.01 | $2,395.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $391.25 / $452.08 / $690.83
| Professional | | $391.25 | $452.08 | $690.83 |