- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $66.11 / $66.11 / $476.11
| Facility | 26 | $66.11 | $66.11 | $476.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $216.00 / $234.30 / $234.30
| Professional | | $216.00 | $234.30 | $234.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $215.43 / $286.85 / $528.19
| Professional | | $215.43 | $286.85 | $528.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.11 / $293.52 / $1,144.69
| Professional | | $190.11 | $293.52 | $1,144.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $266.64 / $583.08 / $583.08
| Professional | | $266.64 | $583.08 | $583.08 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $75.47 / $163.75 / $163.75
| Professional | 26 | $75.47 | $163.75 | $163.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.05 / $316.08 / $826.66
| Professional | | $154.05 | $316.08 | $826.66 |