- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $107.15 / $107.15 / $125.89
| Facility | 26 | $107.15 | $107.15 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $239.88 / $354.81
| Professional | | $190.55 | $239.88 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $245.47 / $380.19
| Professional | | $186.21 | $245.47 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.42 / $288.40 / $389.05
| Professional | | $234.42 | $288.40 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $288.40 / $478.63
| Professional | | $190.55 | $288.40 | $478.63 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $239.88 / $467.74 / $467.74
| Facility | 26 | $239.88 | $467.74 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $302.00 / $1,548.82
| Professional | | $190.55 | $302.00 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $269.15 / $457.09
| Professional | | $173.78 | $269.15 | $457.09 |