- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $98.92 / $98.92 / $98.92
| Facility | 26 | $98.92 | $98.92 | $98.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $372.49 / $405.82 / $469.95
| Professional | | $372.49 | $405.82 | $469.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $475.50 / $528.34 / $799.63
| Professional | | $475.50 | $528.34 | $799.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.67 / $1,049.38 / $1,668.94
| Professional | | $363.67 | $1,049.38 | $1,668.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $411.30 / $929.84 / $929.84
| Professional | | $411.30 | $929.84 | $929.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $109.90 / $243.60 / $243.60
| Professional | 26 | $109.90 | $243.60 | $243.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $214.94 / $519.60 / $1,177.50
| Professional | | $214.94 | $519.60 | $1,177.50 |