- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $62.02 / $77.94 / $77.94
| Facility | 26 | $62.02 | $77.94 | $77.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $189.09 / $215.32 / $236.22
| Professional | | $189.09 | $215.32 | $236.22 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $53.50 / $62.02 / $67.05
| Professional | 26 | $53.50 | $62.02 | $67.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $201.17 / $376.70 / $518.77
| Professional | | $201.17 | $376.70 | $518.77 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $43.80 / $65.34 / $110.04
| Professional | 26 | $43.80 | $65.34 | $110.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $175.00 / $319.04 / $523.79
| Professional | | $175.00 | $319.04 | $523.79 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $48.73 / $71.81 / $141.97
| Professional | 26 | $48.73 | $71.81 | $141.97 |