- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $166.95 / $347.09 / $453.56
| Facility | 26 | $166.95 | $347.09 | $453.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $370.50 / $600.00 / $2,173.00
| Professional | | $370.50 | $600.00 | $2,173.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $375.21 / $857.84 / $1,005.71
| Professional | | $375.21 | $857.84 | $1,005.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.58 / $603.82 / $1,119.05
| Professional | | $446.58 | $603.82 | $1,119.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $384.99 / $492.24 / $695.49
| Professional | | $384.99 | $492.24 | $695.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.33 / $161.33 / $203.41
| Professional | | $161.33 | $161.33 | $203.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.33 / $703.47 / $1,349.37
| Professional | | $389.33 | $703.47 | $1,349.37 |