- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $111.93 / $111.94 / $111.94
| Facility | 26 | $111.93 | $111.94 | $111.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.81 / $260.50 / $367.79
| Professional | | $172.81 | $260.50 | $367.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $222.69 / $296.92 / $412.48
| Professional | | $222.69 | $296.92 | $412.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.08 / $307.61 / $542.50
| Professional | | $90.08 | $307.61 | $542.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.73 / $273.70 / $485.79
| Professional | | $124.73 | $273.70 | $485.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.81 / $261.92 / $367.79
| Professional | | $172.81 | $261.92 | $367.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $244.48 / $341.27 / $552.64
| Professional | | $244.48 | $341.27 | $552.64 |