- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $60.65 / $117.82 / $122.70
| Facility | 26 | $60.65 | $117.82 | $122.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.80 / $209.81 / $232.24
| Professional | | $114.80 | $209.81 | $232.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $264.00 / $264.00 / $264.00
| Professional | | $264.00 | $264.00 | $264.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.97 / $200.24 / $260.81
| Professional | | $122.97 | $200.24 | $260.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $32.34
| Professional | | $32.34 | $32.34 | $32.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.13 / $164.53 / $342.78
| Professional | | $122.13 | $164.53 | $342.78 |