- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $114.96 / $296.57 / $296.57
| Facility | 26 | $114.96 | $296.57 | $296.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $370.50 / $475.00 / $576.17
| Professional | | $370.50 | $475.00 | $576.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $258.45 / $552.19 / $800.67
| Professional | | $258.45 | $552.19 | $800.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $357.77 / $636.44 / $1,284.85
| Professional | | $357.77 | $636.44 | $1,284.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.87 / $525.82 / $974.63
| Professional | | $295.87 | $525.82 | $974.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $383.96 / $533.24 / $1,118.57
| Professional | | $383.96 | $533.24 | $1,118.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $330.25 / $451.87 / $625.49
| Professional | | $330.25 | $451.87 | $625.49 |