- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $66.59 / $69.92 / $69.92
| Facility | 26 | $66.59 | $69.92 | $69.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.01 / $227.85 / $522.50
| Professional | | $181.01 | $227.85 | $522.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $209.08 / $293.33 / $750.00
| Professional | | $209.08 | $293.33 | $750.00 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $137.69 / $137.69 / $137.69
| Facility | 26 | $137.69 | $137.69 | $137.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.38 / $327.20 / $590.00
| Professional | | $204.38 | $327.20 | $590.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $282.10 / $358.05 / $700.00
| Professional | | $282.10 | $358.05 | $700.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $86.57 / $107.88 / $252.62
| Professional | 26 | $86.57 | $107.88 | $252.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $324.30 / $522.94 / $986.70
| Professional | | $324.30 | $522.94 | $986.70 |