- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $98.84 / $98.84 / $98.84
| Facility | 26 | $98.84 | $98.84 | $98.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.00 / $425.81 / $510.97
| Professional | | $250.00 | $425.81 | $510.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.08 / $534.44 / $1,198.74
| Professional | | $118.08 | $534.44 | $1,198.74 |
- 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
- $369.70 / $616.20 / $998.10
| Professional | | $369.70 | $616.20 | $998.10 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $63.67 / $63.67 / $98.84
| Facility | 26 | $63.67 | $63.67 | $98.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $359.71 / $425.81 / $635.85
| Professional | | $359.71 | $425.81 | $635.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.51 / $256.90 / $384.92
| Professional | | $93.51 | $256.90 | $384.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $358.98 / $478.24 / $776.92
| Professional | | $358.98 | $478.24 | $776.92 |