- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $60.93 / $60.93 / $60.93
| Facility | 26 | $60.93 | $60.93 | $60.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.51 / $169.60 / $755.00
| Professional | | $128.51 | $169.60 | $755.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.70 / $195.96 / $315.75
| Professional | | $126.70 | $195.96 | $315.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.14 / $88.11 / $158.49
| Professional | | $53.14 | $88.11 | $158.49 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $198.33 / $198.33 / $198.33
| Facility | 26 | $198.33 | $198.33 | $198.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.59 / $275.99 / $290.86
| Professional | | $234.59 | $275.99 | $290.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.87 / $145.80 / $235.18
| Professional | | $133.87 | $145.80 | $235.18 |