- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $134.66 / $134.66 / $134.66
| Facility | 26 | $134.66 | $134.66 | $134.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $289.05 / $425.00 / $491.13
| Professional | | $289.05 | $425.00 | $491.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $254.90 / $460.00 / $703.35
| Professional | | $254.90 | $460.00 | $703.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.10 / $480.13 / $804.38
| Professional | | $323.10 | $480.13 | $804.38 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $172.53 / $194.29 / $340.61
| Facility | 26 | $172.53 | $194.29 | $340.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $187.72 / $187.72 / $1,063.70
| Professional | | $187.72 | $187.72 | $1,063.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.53 / $178.71 / $320.65
| Professional | | $96.53 | $178.71 | $320.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $301.79 / $418.36 / $830.00
| Professional | | $301.79 | $418.36 | $830.00 |