- 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
- $272.94 / $475.00 / $837.96
| Professional | | $272.94 | $475.00 | $837.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $255.79 / $543.95 / $823.16
| Professional | | $255.79 | $543.95 | $823.16 |
- 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
- $402.53 / $469.74 / $810.94
| Professional | | $402.53 | $469.74 | $810.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.20 / $449.31 / $650.00
| Professional | | $263.20 | $449.31 | $650.00 |