- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $55.71 / $55.71 / $90.34
| Facility | 26 | $55.71 | $55.71 | $90.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.34 / $130.78 / $192.40
| Professional | | $108.34 | $130.78 | $192.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.84 / $307.52 / $321.44
| Professional | | $243.84 | $307.52 | $321.44 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $60.73 / $60.73 / $60.73
| Facility | 26 | $60.73 | $60.73 | $60.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.72 / $265.97 / $602.97
| Professional | | $129.72 | $265.97 | $602.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $287.08 / $3,109.00
| Professional | | $158.49 | $287.08 | $3,109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.19 / $270.55 / $435.21
| Professional | | $150.19 | $270.55 | $435.21 |