- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $115.13 / $115.13 / $115.13
| Facility | 26 | $115.13 | $115.13 | $115.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.00 / $432.33 / $477.14
| Professional | | $275.00 | $432.33 | $477.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.72 / $196.99 / $422.63
| Professional | | $130.72 | $196.99 | $422.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $266.35 / $458.59 / $949.19
| Professional | | $266.35 | $458.59 | $949.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $283.13 / $377.50 / $691.84
| Professional | | $283.13 | $377.50 | $691.84 |