- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $80.73 / $80.73 / $80.73
| Facility | 26 | $80.73 | $80.73 | $80.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.90 / $148.82 / $165.19
| Professional | | $137.90 | $148.82 | $165.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.66 / $144.07 / $214.74
| Professional | | $129.66 | $144.07 | $214.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.31 / $371.10 / $633.04
| Professional | | $163.31 | $371.10 | $633.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.28 / $349.38 / $349.38
| Professional | | $154.28 | $349.38 | $349.38 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $85.43 / $189.71 / $189.71
| Professional | 26 | $85.43 | $189.71 | $189.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.06 / $198.73 / $442.44
| Professional | | $122.06 | $198.73 | $442.44 |