- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $49.19 / $160.72 / $447.12
| Facility | 26 | $49.19 | $160.72 | $447.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $293.02 / $319.74 / $319.74
| Professional | | $293.02 | $319.74 | $319.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $348.27 / $463.20 / $924.46
| Professional | | $348.27 | $463.20 | $924.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $289.08 / $364.75 / $1,643.64
| Professional | | $289.08 | $364.75 | $1,643.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $343.29 / $772.00 / $772.00
| Professional | | $343.29 | $772.00 | $772.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $55.05 / $121.21 / $121.21
| Professional | 26 | $55.05 | $121.21 | $121.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $273.33 / $398.87 / $1,154.83
| Professional | | $273.33 | $398.87 | $1,154.83 |