- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $49.09 / $49.09 / $49.87
| Facility | 26 | $49.09 | $49.09 | $49.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.22 / $173.41 / $263.12
| Professional | | $107.22 | $173.41 | $263.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $365.00 / $600.00 / $600.00
| Professional | | $365.00 | $600.00 | $600.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $210.06 / $283.58 / $477.90
| Professional | | $210.06 | $283.58 | $477.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.91 / $285.16 / $733.69
| Professional | | $204.91 | $285.16 | $733.69 |