- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $114.38 / $114.38 / $114.38
| Facility | 26 | $114.38 | $114.38 | $114.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.20 / $172.29 / $249.24
| Professional | | $127.20 | $172.29 | $249.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $197.54 / $197.54 / $346.25
| Professional | | $197.54 | $197.54 | $346.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.83 / $191.55 / $226.03
| Professional | | $139.83 | $191.55 | $226.03 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $95.64 / $95.64 / $95.64
| Facility | 26 | $95.64 | $95.64 | $95.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.26 / $237.22 / $568.14
| Professional | | $159.26 | $237.22 | $568.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.72 / $182.21 / $260.33
| Professional | | $141.72 | $182.21 | $260.33 |