- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $98.61 / $98.61 / $104.37
| Facility | 26 | $98.61 | $98.61 | $104.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.10 / $220.50 / $253.51
| Professional | | $190.10 | $220.50 | $253.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.94 / $234.17 / $371.92
| Professional | | $170.94 | $234.17 | $371.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.54 / $127.24 / $252.23
| Professional | | $100.54 | $127.24 | $252.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.15 / $270.70 / $479.21
| Professional | | $180.15 | $270.70 | $479.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.84 / $241.63 / $406.06
| Professional | | $170.84 | $241.63 | $406.06 |