- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $225.72 / $225.72 / $225.72
| Facility | 26 | $225.72 | $225.72 | $225.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $254.75 / $276.95 / $344.00
| Professional | | $254.75 | $276.95 | $344.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.74 / $402.75 / $580.09
| Professional | | $257.74 | $402.75 | $580.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.38 / $248.30 / $324.64
| Professional | | $43.38 | $248.30 | $324.64 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $265.56 / $265.56 / $265.56
| Facility | 26 | $265.56 | $265.56 | $265.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $301.23 / $471.35 / $789.75
| Professional | | $301.23 | $471.35 | $789.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $240.83 / $307.49 / $500.77
| Professional | | $240.83 | $307.49 | $500.77 |