- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $93.87 / $93.88 / $93.88
| Facility | 26 | $93.87 | $93.88 | $93.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.99 / $425.00 / $494.18
| Professional | | $275.99 | $425.00 | $494.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $244.35 / $649.11 / $931.91
| Professional | | $244.35 | $649.11 | $931.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.76 / $564.32 / $1,005.62
| Professional | | $316.76 | $564.32 | $1,005.62 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $115.14 / $135.00 / $239.13
| Facility | 26 | $115.14 | $135.00 | $239.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.42 / $300.42 / $1,015.64
| Professional | | $300.42 | $300.42 | $1,015.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.53 / $204.24 / $329.95
| Professional | | $96.53 | $204.24 | $329.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $289.75 / $468.25 / $865.02
| Professional | | $289.75 | $468.25 | $865.02 |