- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $62.16 / $62.16 / $62.16
| Facility | 26 | $62.16 | $62.16 | $62.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.47 / $209.93 / $242.92
| Professional | | $105.47 | $209.93 | $242.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.86 / $218.16 / $476.54
| Professional | | $135.86 | $218.16 | $476.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.57 / $67.28 / $106.37
| Professional | | $32.57 | $67.28 | $106.37 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $2,559.17 / $2,559.17 / $2,559.17
| Facility | 26 | $2,559.17 | $2,559.17 | $2,559.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.47 / $222.32 / $290.14
| Professional | | $176.47 | $222.32 | $290.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.16 / $142.19 / $303.94
| Professional | | $133.16 | $142.19 | $303.94 |