- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $64.03 / $64.03 / $64.03
| Facility | 26 | $64.03 | $64.03 | $64.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.63 / $143.24 / $207.31
| Professional | | $111.63 | $143.24 | $207.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $241.26 / $290.08 / $344.01
| Professional | | $241.26 | $290.08 | $344.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.84 / $266.92 / $417.10
| Professional | | $112.84 | $266.92 | $417.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.36 / $257.33 / $1,240.15
| Professional | | $144.36 | $257.33 | $1,240.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.36 / $251.71 / $328.04
| Professional | | $144.36 | $251.71 | $328.04 |