- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $116.67 / $116.67 / $116.67
| Facility | 26 | $116.67 | $116.67 | $116.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.00 / $425.00 / $475.00
| Professional | | $275.00 | $425.00 | $475.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.08 / $173.42 / $372.05
| Professional | | $115.08 | $173.42 | $372.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $221.85 / $492.67 / $897.47
| Professional | | $221.85 | $492.67 | $897.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $247.72 / $309.64 / $783.49
| Professional | | $247.72 | $309.64 | $783.49 |