- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $61.96 / $163.16 / $313.49
| Facility | 26 | $61.96 | $163.16 | $313.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $171.00 / $211.62 / $530.55
| Professional | | $171.00 | $211.62 | $530.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.38 / $255.00 / $575.63
| Professional | | $158.38 | $255.00 | $575.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.36 / $325.98 / $640.67
| Professional | | $208.36 | $325.98 | $640.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $264.50 / $421.65 / $1,176.00
| Professional | | $264.50 | $421.65 | $1,176.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $79.13 / $126.15 / $446.88
| Professional | 26 | $79.13 | $126.15 | $446.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.40 / $266.76 / $444.83
| Professional | | $106.40 | $266.76 | $444.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $193.88 / $263.39 / $571.94
| Professional | | $193.88 | $263.39 | $571.94 |