- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $186.21 / $186.21 / $186.21
| Facility | 26 | $186.21 | $186.21 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.50 / $147.91 / $363.08
| Professional | | $95.50 | $147.91 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Professional | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $177.83 / $245.47
| Professional | | $123.03 | $177.83 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.90 / $208.93 / $346.74
| Professional | | $134.90 | $208.93 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $213.80 / $323.59
| Professional | | $138.04 | $213.80 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $162.18 / $323.59
| Professional | | $125.89 | $162.18 | $323.59 |