- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $101.20 / $166.74 / $166.74
| Facility | 26 | $101.20 | $166.74 | $166.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.00 / $426.47 / $515.97
| Professional | | $275.00 | $426.47 | $515.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.63 / $162.63 / $162.63
| Professional | | $162.63 | $162.63 | $162.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.35 / $249.15 / $534.54
| Professional | | $165.35 | $249.15 | $534.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $225.55 / $401.61 / $834.13
| Professional | | $225.55 | $401.61 | $834.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.88 / $339.01 / $672.56
| Professional | | $243.88 | $339.01 | $672.56 |