- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $112.21 / $112.21 / $172.96
| Facility | 26 | $112.21 | $112.21 | $172.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $287.26 / $343.58 / $475.00
| Professional | | $287.26 | $343.58 | $475.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $329.62 / $545.28 / $799.25
| Professional | | $329.62 | $545.28 | $799.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.46 / $191.26 / $344.72
| Professional | | $107.46 | $191.26 | $344.72 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $125.89 / $125.89 / $125.89
| Facility | 26 | $125.89 | $125.89 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $280.89 / $521.51 / $801.10
| Professional | | $280.89 | $521.51 | $801.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $287.64 / $406.08 / $711.84
| Professional | | $287.64 | $406.08 | $711.84 |