- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $64.90 / $64.90 / $75.90
| Facility | 26 | $64.90 | $64.90 | $75.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $312.36 / $392.00 / $604.77
| Professional | | $312.36 | $392.00 | $604.77 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $48.28 / $62.11 / $64.91
| Professional | 26 | $48.28 | $62.11 | $64.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $225.61 / $299.20 / $1,018.04
| Professional | | $225.61 | $299.20 | $1,018.04 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $36.92 / $49.58 / $203.11
| Professional | 26 | $36.92 | $49.58 | $203.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $283.19 / $463.05 / $883.43
| Professional | | $283.19 | $463.05 | $883.43 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $47.84 / $80.62 / $177.36
| Professional | 26 | $47.84 | $80.62 | $177.36 |