- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $220.00 / $220.00 / $220.00
| Facility | 26 | $220.00 | $220.00 | $220.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.63 / $210.25 / $212.84
| Professional | | $192.63 | $210.25 | $212.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $256.72 / $256.72 / $446.65
| Professional | | $256.72 | $256.72 | $446.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $267.41 / $491.59 / $495.25
| Professional | | $267.41 | $491.59 | $495.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.61 / $187.49 / $378.98
| Professional | | $148.61 | $187.49 | $378.98 |