- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $131.34 / $166.62 / $195.14
| Facility | 26 | $131.34 | $166.62 | $195.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $437.60 / $475.00 / $650.14
| Professional | | $437.60 | $475.00 | $650.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $787.00 / $787.00 / $787.00
| Professional | | $787.00 | $787.00 | $787.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $221.85 / $580.00 / $957.43
| Professional | | $221.85 | $580.00 | $957.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $204.91
| Professional | | $32.34 | $32.34 | $204.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $278.69 / $376.56 / $953.84
| Professional | | $278.69 | $376.56 | $953.84 |