- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $49.73 / $85.62 / $109.21
| Facility | 26 | $49.73 | $85.62 | $109.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.38 / $188.50 / $233.83
| Professional | | $102.38 | $188.50 | $233.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $470.00 / $470.00 / $470.00
| Professional | | $470.00 | $470.00 | $470.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.64 / $220.33 / $536.28
| Professional | | $97.64 | $220.33 | $536.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $91.88
| Professional | | $32.34 | $32.34 | $91.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.23 / $159.80 / $538.28
| Professional | | $118.23 | $159.80 | $538.28 |