- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $45.74 / $120.12 / $120.12
| Facility | 26 | $45.74 | $120.12 | $120.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.44 / $169.28 / $546.38
| Professional | | $157.44 | $169.28 | $546.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $221.25 / $324.83 / $471.00
| Professional | | $221.25 | $324.83 | $471.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.97 / $533.07 / $713.55
| Professional | | $295.97 | $533.07 | $713.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.62 / $455.00 / $935.58
| Professional | | $257.62 | $455.00 | $935.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $189.60 / $332.57 / $1,824.77
| Professional | | $189.60 | $332.57 | $1,824.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.68 / $244.43 / $374.94
| Professional | | $173.68 | $244.43 | $374.94 |