- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $141.50 / $141.50 / $219.60
| Facility | 26 | $141.50 | $141.50 | $219.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $404.29 / $465.01 / $604.29
| Professional | | $404.29 | $465.01 | $604.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $497.75 / $801.20 / $1,137.70
| Professional | | $497.75 | $801.20 | $1,137.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.44 / $282.00 / $521.49
| Professional | | $136.44 | $282.00 | $521.49 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $159.58 / $159.58 / $159.58
| Facility | 26 | $159.58 | $159.58 | $159.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $424.92 / $859.88 / $1,283.36
| Professional | | $424.92 | $859.88 | $1,283.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $450.11 / $659.59 / $1,179.90
| Professional | | $450.11 | $659.59 | $1,179.90 |