- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $114.89 / $114.89 / $114.89
| Facility | 26 | $114.89 | $114.89 | $114.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $313.82 / $400.89 / $540.57
| Professional | | $313.82 | $400.89 | $540.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $734.22 / $890.37 / $979.45
| Professional | | $734.22 | $890.37 | $979.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $320.27 / $849.28 / $1,283.40
| Professional | | $320.27 | $849.28 | $1,283.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.07 / $821.66 / $2,594.32
| Professional | | $398.07 | $821.66 | $2,594.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.07 / $735.15 / $944.27
| Professional | | $398.07 | $735.15 | $944.27 |