- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $128.00 / $128.00 / $128.00
| Facility | 26 | $128.00 | $128.00 | $128.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $278.80 / $475.00 / $856.29
| Professional | | $278.80 | $475.00 | $856.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $260.76 / $541.58 / $820.21
| Professional | | $260.76 | $541.58 | $820.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.95 / $173.89 / $261.12
| Professional | | $79.95 | $173.89 | $261.12 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $669.98 / $669.98 / $669.98
| Facility | 26 | $669.98 | $669.98 | $669.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $410.45 / $479.00 / $805.37
| Professional | | $410.45 | $479.00 | $805.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $267.50 / $396.49 / $650.00
| Professional | | $267.50 | $396.49 | $650.00 |