- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $102.33 / $165.96 / $165.96
| Facility | 26 | $102.33 | $165.96 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $426.58 / $724.44
| Professional | | $288.40 | $426.58 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $162.18 / $162.18
| Professional | | $162.18 | $162.18 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.96 / $457.09 / $537.03
| Professional | | $165.96 | $457.09 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $457.09 / $831.76
| Professional | | $302.00 | $457.09 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $354.81 / $676.08
| Professional | | $245.47 | $354.81 | $676.08 |