- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $64.57 / $64.57 / $64.57
| Facility | 26 | $64.57 | $64.57 | $64.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $199.53 / $302.00
| Professional | | $169.82 | $199.53 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $204.17 / $239.88
| Professional | | $141.25 | $204.17 | $239.88 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $12.59 / $58.88 / $85.11
| Facility | 26 | $12.59 | $58.88 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $213.80 / $436.52
| Professional | | $138.04 | $213.80 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.82 / $181.97 / $275.42
| Professional | | $128.82 | $181.97 | $275.42 |