- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $103.92 / $103.92 / $121.85
| Facility | 26 | $103.92 | $103.92 | $121.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $217.47 / $259.48 / $364.19
| Professional | | $217.47 | $259.48 | $364.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $258.60 / $304.24 / $304.24
| Professional | | $258.60 | $304.24 | $304.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $214.05 / $326.73 / $644.00
| Professional | | $214.05 | $326.73 | $644.00 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $192.32 / $192.32 / $192.32
| Facility | 26 | $192.32 | $192.32 | $192.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $217.98 / $310.36 / $1,687.36
| Professional | | $217.98 | $310.36 | $1,687.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.44 / $272.14 / $445.55
| Professional | | $211.44 | $272.14 | $445.55 |