- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $79.08 / $205.31 / $205.31
| Facility | 26 | $79.08 | $205.31 | $205.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.29 / $188.50 / $211.76
| Professional | | $107.29 | $188.50 | $211.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.86 / $167.16 / $242.38
| Professional | | $113.86 | $167.16 | $242.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.62 / $258.33 / $521.54
| Professional | | $150.62 | $258.33 | $521.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.35 / $225.48 / $429.39
| Professional | | $130.35 | $225.48 | $429.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.09 / $227.88 / $600.05
| Professional | | $164.09 | $227.88 | $600.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.52 / $142.44 / $215.50
| Professional | | $103.52 | $142.44 | $215.50 |