- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $46.07 / $177.07 / $177.07
| Facility | 26 | $46.07 | $177.07 | $177.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $191.43 / $215.12 / $712.23
| Professional | | $191.43 | $215.12 | $712.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.05 / $302.51 / $438.63
| Professional | | $206.05 | $302.51 | $438.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.14 / $509.07 / $678.13
| Professional | | $275.14 | $509.07 | $678.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.91 / $419.21 / $1,205.61
| Professional | | $239.91 | $419.21 | $1,205.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.57 / $309.00 / $1,561.61
| Professional | | $250.57 | $309.00 | $1,561.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.22 / $222.49 / $335.55
| Professional | | $190.22 | $222.49 | $335.55 |