- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $119.08 / $119.08 / $119.08
| Facility | 26 | $119.08 | $119.08 | $119.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $369.25 / $445.06 / $815.91
| Professional | | $369.25 | $445.06 | $815.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $347.60 / $477.49 / $561.88
| Professional | | $347.60 | $477.49 | $561.88 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $85.84 / $85.84 / $85.84
| Facility | 26 | $85.84 | $85.84 | $85.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $399.50 / $490.78 / $1,303.95
| Professional | | $399.50 | $490.78 | $1,303.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $262.63 / $408.48 / $537.09
| Professional | | $262.63 | $408.48 | $537.09 |