- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $107.02 / $107.02 / $107.02
| Facility | 26 | $107.02 | $107.02 | $107.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.61 / $283.50 / $519.67
| Professional | | $208.61 | $283.50 | $519.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $238.34 / $314.44 / $483.52
| Professional | | $238.34 | $314.44 | $483.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.48 / $117.48 / $226.42
| Professional | | $79.48 | $117.48 | $226.42 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $484.37 / $484.37 / $484.37
| Facility | 26 | $484.37 | $484.37 | $484.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $297.20 / $362.27 / $393.61
| Professional | | $297.20 | $362.27 | $393.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.20 / $217.98 / $434.88
| Professional | | $186.20 | $217.98 | $434.88 |