- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $67.18 / $67.18 / $67.18
| Facility | 26 | $67.18 | $67.18 | $67.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.87 / $116.87 / $202.30
| Professional | | $116.87 | $116.87 | $202.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.28 / $458.37 / $664.63
| Professional | | $107.28 | $458.37 | $664.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.41 / $230.75 / $766.51
| Professional | | $127.41 | $230.75 | $766.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $311.02 / $567.22 / $1,059.26
| Professional | | $311.02 | $567.22 | $1,059.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.82 / $281.50 / $291.36
| Professional | | $174.82 | $281.50 | $291.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $222.85 / $260.29 / $2,500.00
| Professional | | $222.85 | $260.29 | $2,500.00 |