- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $57.54 / $57.54 / $57.54
| Facility | 26 | $57.54 | $57.54 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $154.88 / $602.56
| Professional | | $100.00 | $154.88 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $158.49 / $223.87
| Professional | | $114.82 | $158.49 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $33.11 / $102.33
| Professional | | $32.36 | $33.11 | $102.33 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $199.53 / $199.53 / $199.53
| Facility | 26 | $199.53 | $199.53 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.96 / $213.80 / $257.04
| Professional | | $165.96 | $213.80 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.49 / $181.97 / $251.19
| Professional | | $117.49 | $181.97 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.61 / $104.71 / $199.53
| Professional | | $67.61 | $104.71 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $123.03 / $208.93
| Professional | | $112.20 | $123.03 | $208.93 |