- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $102.33 / $102.33 / $102.33
| Facility | 26 | $102.33 | $102.33 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $251.19 / $478.63
| Professional | | $186.21 | $251.19 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.80 / $489.78 / $724.44
| Professional | | $213.80 | $489.78 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $501.19 / $741.31
| Professional | | $288.40 | $501.19 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $389.05 / $602.56
| Professional | | $245.47 | $389.05 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $407.38 / $1,023.29
| Professional | | $251.19 | $407.38 | $1,023.29 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $43.65 / $51.29 / $51.29
| Facility | 26 | $43.65 | $51.29 | $51.29 |