- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $54.74 / $54.74 / $54.74
| Facility | 26 | $54.74 | $54.74 | $54.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.98 / $137.76 / $242.97
| Professional | | $108.98 | $137.76 | $242.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.08 / $112.85 / $233.43
| Professional | | $52.08 | $112.85 | $233.43 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $64.00 / $64.00 / $64.00
| Facility | 26 | $64.00 | $64.00 | $64.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.45 / $151.02 / $332.38
| Professional | | $93.45 | $151.02 | $332.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $299.89 / $299.89 / $299.89
| Professional | | $299.89 | $299.89 | $299.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.18 / $120.44 / $236.31
| Professional | | $88.18 | $120.44 | $236.31 |