- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $93.88 / $93.88 / $93.88
| Facility | 26 | $93.88 | $93.88 | $93.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $270.17 / $425.00 / $598.50
| Professional | | $270.17 | $425.00 | $598.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $240.21 / $460.00 / $717.68
| Professional | | $240.21 | $460.00 | $717.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $311.43 / $566.37 / $992.33
| Professional | | $311.43 | $566.37 | $992.33 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $116.18 / $135.00 / $226.08
| Facility | 26 | $116.18 | $135.00 | $226.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.42 / $300.42 / $994.23
| Professional | | $300.42 | $300.42 | $994.23 |
- 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
- $285.17 / $462.71 / $866.66
| Professional | | $285.17 | $462.71 | $866.66 |