- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $356.79 / $356.79 / $356.79
| Facility | 26 | $356.79 | $356.79 | $356.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.47 / $126.19 / $730.00
| Professional | | $94.47 | $126.19 | $730.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.58 / $141.86 / $242.57
| Professional | | $120.58 | $141.86 | $242.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.21 / $167.21 / $246.81
| Professional | | $115.21 | $167.21 | $246.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.92 / $128.57 / $216.28
| Professional | | $106.92 | $128.57 | $216.28 |