- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $41.57 / $41.57 / $87.63
| Facility | 26 | $41.57 | $41.57 | $87.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.80 / $320.67 / $1,864.00
| Professional | | $248.80 | $320.67 | $1,864.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.01 / $209.72 / $376.89
| Professional | | $52.01 | $209.72 | $376.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $324.17 / $471.11 / $646.29
| Professional | | $324.17 | $471.11 | $646.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $85.04 / $462.50
| Professional | | $32.34 | $85.04 | $462.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $264.56 / $521.59 / $646.29
| Professional | | $264.56 | $521.59 | $646.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $255.10 / $309.67 / $714.30
| Professional | | $255.10 | $309.67 | $714.30 |