- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $56.23 / $56.23 / $104.71
| Facility | 26 | $56.23 | $56.23 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $204.17 / $302.00
| Professional | | $173.78 | $204.17 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $234.42 / $416.87
| Professional | | $158.49 | $234.42 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $223.87 / $407.38
| Professional | | $147.91 | $223.87 | $407.38 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $331.13 / $331.13 / $331.13
| Facility | 26 | $331.13 | $331.13 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,513.56 / $1,513.56
| Professional | | $1,318.26 | $1,513.56 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $218.78 / $380.19
| Professional | | $141.25 | $218.78 | $380.19 |