- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $102.33 / $102.33 / $102.33
| Facility | 26 | $102.33 | $102.33 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $79.43 / $234.42
| Professional | | $60.26 | $79.43 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $162.18 / $162.18
| Professional | | $162.18 | $162.18 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.18 / $102.33 / $141.25
| Professional | | $69.18 | $102.33 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.10 / $128.82 / $204.17
| Professional | | $87.10 | $128.82 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.86 / $117.49 / $186.21
| Professional | | $75.86 | $117.49 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.62 / $102.33 / $194.98
| Professional | | $77.62 | $102.33 | $194.98 |