- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $81.17 / $81.17 / $81.17
| Facility | 26 | $81.17 | $81.17 | $81.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $220.00 / $261.32 / $305.87
| Professional | | $220.00 | $261.32 | $305.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $293.89 / $324.00 / $527.05
| Professional | | $293.89 | $324.00 | $527.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.44 / $340.18 / $612.16
| Professional | | $250.44 | $340.18 | $612.16 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $137.79 / $138.77 / $286.42
| Facility | 26 | $137.79 | $138.77 | $286.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $276.29 / $276.29 / $276.29
| Professional | | $276.29 | $276.29 | $276.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.64 / $246.00 / $415.03
| Professional | | $95.64 | $246.00 | $415.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.14 / $321.16 / $559.34
| Professional | | $218.14 | $321.16 | $559.34 |