- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $71.41 / $71.41 / $71.41
| Facility | 26 | $71.41 | $71.41 | $71.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $205.33 / $236.09 / $473.85
| Professional | | $205.33 | $236.09 | $473.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.97 / $85.97 / $85.97
| Professional | | $85.97 | $85.97 | $85.97 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $86.12 / $86.12 / $86.12
| Facility | 26 | $86.12 | $86.12 | $86.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $202.13 / $329.18 / $1,636.07
| Professional | | $202.13 | $329.18 | $1,636.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.37 / $291.08 / $426.13
| Professional | | $157.37 | $291.08 | $426.13 |