- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $38.83 / $38.83 / $38.83
| Facility | 26 | $38.83 | $38.83 | $38.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $314.19 / $354.91 / $474.28
| Professional | | $314.19 | $354.91 | $474.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $414.86 / $460.96 / $585.41
| Professional | | $414.86 | $460.96 | $585.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.64 / $464.89 / $889.77
| Professional | | $286.64 | $464.89 | $889.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $364.82 / $441.30 / $702.44
| Professional | | $364.82 | $441.30 | $702.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $44.88 / $52.51 / $74.47
| Professional | 26 | $44.88 | $52.51 | $74.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $327.72 / $411.00 / $719.04
| Professional | | $327.72 | $411.00 | $719.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $294.20 / $403.58 / $521.17
| Professional | | $294.20 | $403.58 | $521.17 |