- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $166.95 / $383.03 / $501.25
| Facility | 26 | $166.95 | $383.03 | $501.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $397.77 / $556.50 / $1,435.00
| Professional | | $397.77 | $556.50 | $1,435.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $301.66 / $838.18 / $1,069.85
| Professional | | $301.66 | $838.18 | $1,069.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $401.65 / $675.65 / $962.98
| Professional | | $401.65 | $675.65 | $962.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $327.02 / $580.79 / $762.46
| Professional | | $327.02 | $580.79 | $762.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.76 / $158.76 / $158.76
| Professional | | $158.76 | $158.76 | $158.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $283.77 / $567.20 / $1,490.82
| Professional | | $283.77 | $567.20 | $1,490.82 |