- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $96.04 / $96.04 / $96.04
| Facility | 26 | $96.04 | $96.04 | $96.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.97 / $164.62 / $164.62
| Professional | | $143.97 | $164.62 | $164.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.68 / $214.16 / $555.01
| Professional | | $181.68 | $214.16 | $555.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.82 / $205.10 / $555.01
| Professional | | $118.82 | $205.10 | $555.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.12 / $204.08 / $340.55
| Professional | | $176.12 | $204.08 | $340.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.89 / $235.87 / $349.75
| Professional | | $213.89 | $235.87 | $349.75 |