- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $39.02 / $125.94 / $353.97
| Facility | 26 | $39.02 | $125.94 | $353.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $193.96 / $211.16 / $211.16
| Professional | | $193.96 | $211.16 | $211.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $254.03 / $276.89 / $894.59
| Professional | | $254.03 | $276.89 | $894.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $193.08 / $371.23 / $1,075.24
| Professional | | $193.08 | $371.23 | $1,075.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.28 / $511.33 / $511.33
| Professional | | $229.28 | $511.33 | $511.33 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $43.98 / $96.02 / $96.02
| Professional | 26 | $43.98 | $96.02 | $96.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $195.69 / $566.02 / $764.89
| Professional | | $195.69 | $566.02 | $764.89 |