- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $118.29 / $118.29 / $118.29
| Facility | 26 | $118.29 | $118.29 | $118.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.10 / $221.26 / $269.04
| Professional | | $190.10 | $221.26 | $269.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $214.94 / $319.05 / $578.04
| Professional | | $214.94 | $319.05 | $578.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.64 / $120.71 / $226.42
| Professional | | $80.64 | $120.71 | $226.42 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $253.98 / $253.98 / $253.98
| Facility | 26 | $253.98 | $253.98 | $253.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $265.45 / $363.03 / $477.96
| Professional | | $265.45 | $363.03 | $477.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $178.80 / $267.91 / $377.22
| Professional | | $178.80 | $267.91 | $377.22 |