- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $90.34 / $90.34 / $146.69
| Facility | 26 | $90.34 | $90.34 | $146.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $327.37 / $416.60 / $518.83
| Professional | | $327.37 | $416.60 | $518.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.14 / $110.02 / $391.27
| Professional | | $104.14 | $110.02 | $391.27 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $104.54 / $104.54 / $104.54
| Facility | 26 | $104.54 | $104.54 | $104.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $292.81 / $441.75 / $993.20
| Professional | | $292.81 | $441.75 | $993.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $221.88 / $304.52 / $507.14
| Professional | | $221.88 | $304.52 | $507.14 |