- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $70.09 / $70.09 / $205.30
| Facility | 26 | $70.09 | $70.09 | $205.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.91 / $236.09 / $597.16
| Professional | | $203.91 | $236.09 | $597.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $425.00 / $425.00 / $425.00
| Professional | | $425.00 | $425.00 | $425.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.18 / $331.46 / $412.96
| Professional | | $190.18 | $331.46 | $412.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $32.34
| Professional | | $32.34 | $32.34 | $32.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.63 / $263.79 / $526.97
| Professional | | $192.63 | $263.79 | $526.97 |