- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $66.67 / $66.67 / $66.67
| Facility | 26 | $66.67 | $66.67 | $66.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.33 / $121.01 / $138.51
| Professional | | $112.33 | $121.01 | $138.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.50 / $179.77 / $512.91
| Professional | | $152.50 | $179.77 | $512.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.11 / $181.36 / $512.91
| Professional | | $107.11 | $181.36 | $512.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.63 / $181.36 / $321.52
| Professional | | $118.63 | $181.36 | $321.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.48 / $201.95 / $587.08
| Professional | | $127.48 | $201.95 | $587.08 |