- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $29.49 / $29.49 / $29.49
| Facility | 26 | $29.49 | $29.49 | $29.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.71 / $174.31 / $238.69
| Professional | | $157.71 | $174.31 | $238.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $241.85 / $298.00 / $372.50
| Professional | | $241.85 | $298.00 | $372.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.29 / $242.60 / $1,025.66
| Professional | | $135.29 | $242.60 | $1,025.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $195.79 / $263.89 / $327.90
| Professional | | $195.79 | $263.89 | $327.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.24 / $231.51 / $272.33
| Professional | | $157.24 | $231.51 | $272.33 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $31.43 / $42.89 / $50.71
| Professional | 26 | $31.43 | $42.89 | $50.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.29 / $242.60 / $314.89
| Professional | | $135.29 | $242.60 | $314.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $280.89 / $343.70 / $343.70
| Professional | | $280.89 | $343.70 | $343.70 |