- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $49.53 / $49.53 / $49.53
| Facility | 26 | $49.53 | $49.53 | $49.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $369.01 / $369.01 / $437.65
| Professional | | $369.01 | $369.01 | $437.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $767.59 / $938.60 / $1,173.25
| Professional | | $767.59 | $938.60 | $1,173.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $527.39 / $818.09 / $2,687.07
| Professional | | $527.39 | $818.09 | $2,687.07 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $148.15 / $148.15 / $148.15
| Facility | 26 | $148.15 | $148.15 | $148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $846.82 / $1,034.05 / $1,064.01
| Professional | | $846.82 | $1,034.05 | $1,064.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $535.96 / $675.21 / $786.04
| Professional | | $535.96 | $675.21 | $786.04 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $54.42 / $81.70 / $93.15
| Professional | 26 | $54.42 | $81.70 | $93.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.32 / $740.93 / $987.90
| Professional | | $489.32 | $740.93 | $987.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $679.40 / $799.30 / $799.30
| Professional | | $679.40 | $799.30 | $799.30 |