- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $116.18 / $116.18 / $116.18
| Facility | 26 | $116.18 | $116.18 | $116.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.00 / $425.00 / $496.86
| Professional | | $275.00 | $425.00 | $496.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.30 / $163.19 / $350.13
| Professional | | $108.30 | $163.19 | $350.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.66 / $472.13 / $896.95
| Professional | | $213.66 | $472.13 | $896.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $242.32 / $327.58 / $780.68
| Professional | | $242.32 | $327.58 | $780.68 |