- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $120.97 / $120.97 / $120.97
| Facility | 26 | $120.97 | $120.97 | $120.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $287.33 / $384.20 / $519.46
| Professional | | $287.33 | $384.20 | $519.46 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $136.12 / $136.12 / $136.12
| Facility | 26 | $136.12 | $136.12 | $136.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $283.08 / $536.10 / $1,067.81
| Professional | | $283.08 | $536.10 | $1,067.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $450.58 / $584.89 / $761.96
| Professional | | $450.58 | $584.89 | $761.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $310.75 / $381.30 / $585.74
| Professional | | $310.75 | $381.30 | $585.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $240.26 / $440.07 / $868.95
| Professional | | $240.26 | $440.07 | $868.95 |