- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $131.85 / $167.26 / $195.89
| Facility | 26 | $131.85 | $167.26 | $195.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $475.00 / $559.09 / $818.33
| Professional | | $475.00 | $559.09 | $818.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $756.00 / $756.00 / $756.00
| Professional | | $756.00 | $756.00 | $756.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $278.49 / $614.05 / $955.00
| Professional | | $278.49 | $614.05 | $955.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $255.51
| Professional | | $32.34 | $32.34 | $255.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.29 / $443.66 / $963.94
| Professional | | $346.29 | $443.66 | $963.94 |