- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $97.84 / $287.26 / $464.03
| Facility | 26 | $97.84 | $287.26 | $464.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.40 / $207.40 / $328.03
| Professional | | $112.40 | $207.40 | $328.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.02 / $232.57 / $270.91
| Professional | | $140.02 | $232.57 | $270.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $178.02 / $203.84 / $357.77
| Professional | | $178.02 | $203.84 | $357.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.93 / $183.10 / $192.05
| Professional | | $132.93 | $183.10 | $192.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.92 / $202.22 / $349.78
| Professional | | $120.92 | $202.22 | $349.78 |