- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $163.29 / $163.29 / $163.29
| Facility | 26 | $163.29 | $163.29 | $163.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $220.00 / $515.26 / $515.26
| Professional | | $220.00 | $515.26 | $515.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $255.32 / $255.32 / $255.32
| Professional | | $255.32 | $255.32 | $255.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.58 / $292.58 / $345.24
| Professional | | $213.58 | $292.58 | $345.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $240.46 / $294.60 / $772.85
| Professional | | $240.46 | $294.60 | $772.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.37 / $271.73 / $334.11
| Professional | | $204.37 | $271.73 | $334.11 |