- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $105.15 / $105.15 / $105.15
| Facility | 26 | $105.15 | $105.15 | $105.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $499.89 / $608.25 / $684.52
| Professional | | $499.89 | $608.25 | $684.52 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $85.78 / $105.15 / $150.81
| Professional | 26 | $85.78 | $105.15 | $150.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.08 / $435.74 / $514.16
| Professional | | $318.08 | $435.74 | $514.16 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $52.58 / $72.03 / $85.00
| Professional | 26 | $52.58 | $72.03 | $85.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $362.67 / $524.77 / $1,246.40
| Professional | | $362.67 | $524.77 | $1,246.40 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $67.23 / $95.23 / $249.57
| Professional | 26 | $67.23 | $95.23 | $249.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $330.94 / $425.49 / $582.82
| Professional | | $330.94 | $425.49 | $582.82 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $54.54 / $67.23 / $90.25
| Professional | 26 | $54.54 | $67.23 | $90.25 |