- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $102.83 / $102.83 / $178.75
| Facility | 26 | $102.83 | $102.83 | $178.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $273.60 / $475.00 / $700.00
| Professional | | $273.60 | $475.00 | $700.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.40 / $197.27 / $433.72
| Professional | | $97.40 | $197.27 | $433.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.91 / $515.99 / $741.66
| Professional | | $286.91 | $515.99 | $741.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $135.43 / $326.34
| Professional | | $32.34 | $135.43 | $326.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $344.00 / $558.76 / $741.66
| Professional | | $344.00 | $558.76 | $741.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $276.39 / $441.49 / $851.63
| Professional | | $276.39 | $441.49 | $851.63 |