- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $102.40 / $102.40 / $114.75
| Facility | 26 | $102.40 | $102.40 | $114.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $313.82 / $372.49 / $429.66
| Professional | | $313.82 | $372.49 | $429.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.56 / $453.32 / $627.25
| Professional | | $281.56 | $453.32 | $627.25 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $261.33 / $496.55 / $496.55
| Facility | 26 | $261.33 | $496.55 | $496.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $299.25 / $428.36 / $2,594.32
| Professional | | $299.25 | $428.36 | $2,594.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $285.95 / $386.13 / $658.82
| Professional | | $285.95 | $386.13 | $658.82 |