- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $63.10 / $213.80 / $223.87
| Facility | 26 | $63.10 | $213.80 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $257.04 / $416.87
| Professional | | $208.93 | $257.04 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $245.47 / $562.34
| Professional | | $245.47 | $245.47 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $446.68 / $676.08
| Professional | | $275.42 | $446.68 | $676.08 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $245.47 / $245.47 / $245.47
| Facility | 26 | $245.47 | $245.47 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,290.87 / $2,290.87
| Professional | | $1,862.09 | $2,290.87 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $371.54 / $645.65
| Professional | | $288.40 | $371.54 | $645.65 |