- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $62.10 / $62.10 / $62.10
| Facility | 26 | $62.10 | $62.10 | $62.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.60 / $192.09 / $225.55
| Professional | | $108.60 | $192.09 | $225.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.28 / $163.53 / $226.35
| Professional | | $121.28 | $163.53 | $226.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.84 / $226.46 / $530.53
| Professional | | $147.84 | $226.46 | $530.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.09 / $170.22 / $314.95
| Professional | | $145.09 | $170.22 | $314.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.06 / $192.09 / $225.55
| Professional | | $128.06 | $192.09 | $225.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.63 / $190.01 / $306.91
| Professional | | $123.63 | $190.01 | $306.91 |