- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $58.61 / $58.61 / $58.61
| Facility | 26 | $58.61 | $58.61 | $58.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.96 / $131.09 / $151.03
| Professional | | $103.96 | $131.09 | $151.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.81 / $211.21 / $295.00
| Professional | | $129.81 | $211.21 | $295.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $259.51 / $280.75 / $337.24
| Professional | | $259.51 | $280.75 | $337.24 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $274.01 / $274.01 / $274.01
| Facility | 26 | $274.01 | $274.01 | $274.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.80 / $263.74 / $1,240.15
| Professional | | $158.80 | $263.74 | $1,240.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.13 / $266.00 / $348.11
| Professional | | $158.13 | $266.00 | $348.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.09 / $126.66 / $255.17
| Professional | | $67.09 | $126.66 | $255.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $179.58 / $254.09 / $329.04
| Professional | | $179.58 | $254.09 | $329.04 |