- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $78.12 / $78.12 / $120.16
| Facility | 26 | $78.12 | $78.12 | $120.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $270.02 / $322.55 / $475.00
| Professional | | $270.02 | $322.55 | $475.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $341.50 / $410.01 / $635.51
| Professional | | $341.50 | $410.01 | $635.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.54 / $211.52 / $325.30
| Professional | | $75.54 | $211.52 | $325.30 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $87.60 / $87.60 / $87.60
| Facility | 26 | $87.60 | $87.60 | $87.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $266.89 / $592.57 / $1,009.29
| Professional | | $266.89 | $592.57 | $1,009.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $278.69 / $464.48 / $824.69
| Professional | | $278.69 | $464.48 | $824.69 |