- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $105.69 / $142.68 / $142.68
| Facility | 26 | $105.69 | $142.68 | $142.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.72 / $147.13 / $184.82
| Professional | | $121.72 | $147.13 | $184.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.03 / $103.03 / $121.22
| Professional | | $103.03 | $103.03 | $121.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.40 / $145.76 / $172.00
| Professional | | $106.40 | $145.76 | $172.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.91 / $167.53 / $523.98
| Professional | | $133.91 | $167.53 | $523.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.62 / $142.88 / $229.93
| Professional | | $107.62 | $142.88 | $229.93 |