- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $43.61 / $43.61 / $80.62
| Facility | 26 | $43.61 | $43.61 | $80.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.75 / $226.70 / $311.93
| Professional | | $168.75 | $226.70 | $311.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $352.00 / $352.00 / $352.00
| Professional | | $352.00 | $352.00 | $352.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.05 / $271.33 / $409.86
| Professional | | $170.05 | $271.33 | $409.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $111.04
| Professional | | $32.34 | $32.34 | $111.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $179.21 / $228.49 / $288.56
| Professional | | $179.21 | $228.49 | $288.56 |