- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $104.71 / $213.80 / $281.84
| Facility | 26 | $104.71 | $213.80 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $407.38 / $549.54
| Professional | | $323.59 | $407.38 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $436.52 / $831.76
| Professional | | $281.84 | $436.52 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $446.68 / $851.14
| Professional | | $295.12 | $446.68 | $851.14 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $676.08 / $676.08 / $676.08
| Facility | 26 | $676.08 | $676.08 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,235.94 / $3,235.94
| Professional | | $2,570.40 | $3,235.94 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $436.52 / $724.44
| Professional | | $269.15 | $436.52 | $724.44 |