- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $88.74 / $88.74 / $143.01
| Facility | 26 | $88.74 | $88.74 | $143.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.29 / $139.61 / $151.16
| Professional | | $126.29 | $139.61 | $151.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $259.92 / $281.33 / $332.40
| Professional | | $259.92 | $281.33 | $332.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $179.46 / $255.65 / $340.27
| Professional | | $179.46 | $255.65 | $340.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.47 / $276.68 / $1,114.00
| Professional | | $141.47 | $276.68 | $1,114.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.40 / $249.01 / $349.51
| Professional | | $134.40 | $249.01 | $349.51 |