- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $94.40 / $122.33 / $190.91
| Facility | 26 | $94.40 | $122.33 | $190.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $340.71 / $425.00 / $640.00
| Professional | | $340.71 | $425.00 | $640.00 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $86.16 / $86.16 / $86.16
| Facility | 26 | $86.16 | $86.16 | $86.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $335.93 / $450.98 / $963.20
| Professional | | $335.93 | $450.98 | $963.20 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $87.95 / $87.95 / $87.95
| Facility | 26 | $87.95 | $87.95 | $87.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $339.96 / $618.42 / $992.69
| Professional | | $339.96 | $618.42 | $992.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $358.98 / $534.03 / $888.18
| Professional | | $358.98 | $534.03 | $888.18 |