- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $53.97 / $56.13 / $310.45
| Facility | 26 | $53.97 | $56.13 | $310.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.79 / $144.79 / $148.05
| Professional | | $144.79 | $144.79 | $148.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.18 / $112.00 / $153.79
| Professional | | $67.18 | $112.00 | $153.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.69 / $109.43 / $144.79
| Professional | | $94.69 | $109.43 | $144.79 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $130.27 / $296.93 / $296.93
| Facility | 26 | $130.27 | $296.93 | $296.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $149.57 / $1,548.00
| Professional | | $107.15 | $149.57 | $1,548.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $99.03 / $120.08 / $179.31
| Professional | | $99.03 | $120.08 | $179.31 |