- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $288.40 / $288.40 / $288.40
| Facility | 26 | $288.40 | $288.40 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.57 / $123.03 / $186.21
| Professional | | $64.57 | $123.03 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.18 / $102.33 / $169.82
| Professional | | $69.18 | $102.33 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $102.33 / $151.36 / $208.93
| Professional | 50 | $102.33 | $151.36 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.10 / $162.18 / $354.81
| Professional | | $87.10 | $162.18 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.86 / $123.03 / $181.97
| Professional | | $75.86 | $123.03 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.20 / $141.25 / $323.59
| Professional | | $91.20 | $141.25 | $323.59 |