- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $78.90 / $110.00 / $129.12
| Facility | 26 | $78.90 | $110.00 | $129.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.49 / $550.00 / $600.00
| Professional | | $281.49 | $550.00 | $600.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $370.60 / $448.01 / $738.85
| Professional | | $370.60 | $448.01 | $738.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.77 / $324.49 / $706.03
| Professional | | $166.77 | $324.49 | $706.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $267.50 / $377.64 / $734.28
| Professional | | $267.50 | $377.64 | $734.28 |