- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $64.29 / $64.29 / $64.29
| Facility | 26 | $64.29 | $64.29 | $64.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.87 / $182.21 / $648.00
| Professional | | $113.87 | $182.21 | $648.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.89 / $162.19 / $239.51
| Professional | | $126.89 | $162.19 | $239.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $65.98 / $98.98
| Professional | | $32.34 | $65.98 | $98.98 |
- 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
- $172.02 / $214.03 / $251.80
| Professional | | $172.02 | $214.03 | $251.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.51 / $127.41 / $211.24
| Professional | | $122.51 | $127.41 | $211.24 |