- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $50.15 / $166.93 / $216.89
| Facility | 26 | $50.15 | $166.93 | $216.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.13 / $221.60 / $657.00
| Professional | | $138.13 | $221.60 | $657.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.22 / $363.95 / $447.56
| Professional | | $150.22 | $363.95 | $447.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.52 / $218.83 / $507.85
| Professional | | $153.52 | $218.83 | $507.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.29 / $222.68 / $260.81
| Professional | | $177.29 | $222.68 | $260.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.02 / $107.40 / $250.38
| Professional | | $55.02 | $107.40 | $250.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.02 / $238.94 / $546.95
| Professional | | $147.02 | $238.94 | $546.95 |