- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $26.86 / $26.86 / $42.53
| Facility | 26 | $26.86 | $26.86 | $42.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.65 / $108.80 / $261.33
| Professional | | $87.65 | $108.80 | $261.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $207.77 / $256.41 / $268.00
| Professional | | $207.77 | $256.41 | $268.00 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $29.00 / $29.00 / $29.00
| Facility | 26 | $29.00 | $29.00 | $29.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.19 / $224.34 / $569.20
| Professional | | $106.19 | $224.34 | $569.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.93 / $239.44 / $2,945.80
| Professional | | $131.93 | $239.44 | $2,945.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.94 / $214.64 / $363.60
| Professional | | $119.94 | $214.64 | $363.60 |