- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $123.54 / $123.54 / $123.54
| Facility | 26 | $123.54 | $123.54 | $123.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.29 / $152.32 / $201.85
| Professional | | $130.29 | $152.32 | $201.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.65 / $207.76 / $336.85
| Professional | | $142.65 | $207.76 | $336.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $171.68 / $258.05 / $453.40
| Professional | | $171.68 | $258.05 | $453.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.30 / $269.20 / $504.03
| Professional | | $163.30 | $269.20 | $504.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.64 / $242.48 / $466.06
| Professional | | $174.64 | $242.48 | $466.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.73 / $142.47 / $209.44
| Professional | | $118.73 | $142.47 | $209.44 |