- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $85.19 / $85.19 / $85.19
| Facility | 26 | $85.19 | $85.19 | $85.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $252.41 / $254.57 / $259.69
| Professional | | $252.41 | $254.57 | $259.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.84 / $175.18 / $291.72
| Professional | | $73.84 | $175.18 | $291.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.57 / $268.98 / $311.33
| Professional | | $194.57 | $268.98 | $311.33 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $192.32 / $339.11 / $339.11
| Facility | 26 | $192.32 | $339.11 | $339.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $189.64 / $288.00 / $1,687.36
| Professional | | $189.64 | $288.00 | $1,687.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.75 / $243.20 / $371.20
| Professional | | $174.75 | $243.20 | $371.20 |