- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $114.82 / $114.82 / $114.82
| Facility | 26 | $114.82 | $114.82 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $169.82 / $371.54
| Professional | | $120.23 | $169.82 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $213.80 / $302.00
| Professional | | $151.36 | $213.80 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $331.13 / $457.09
| Professional | | $186.21 | $331.13 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $309.03 / $467.74
| Professional | | $173.78 | $309.03 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.96 / $199.53 / $512.86
| Professional | | $165.96 | $199.53 | $512.86 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $54.95 / $54.95 / $54.95
| Facility | 26 | $54.95 | $54.95 | $54.95 |