- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $54.63 / $54.63 / $88.61
| Facility | 26 | $54.63 | $54.63 | $88.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.59 / $124.50 / $194.42
| Professional | | $102.59 | $124.50 | $194.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $237.37 / $292.92 / $306.17
| Professional | | $237.37 | $292.92 | $306.17 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $60.76 / $60.76 / $60.76
| Facility | 26 | $60.76 | $60.76 | $60.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.17 / $251.86 / $614.04
| Professional | | $124.17 | $251.86 | $614.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.00 / $275.16 / $3,099.85
| Professional | | $152.00 | $275.16 | $3,099.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.60 / $246.35 / $410.60
| Professional | | $144.60 | $246.35 | $410.60 |