- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $89.45 / $89.46 / $381.91
| Facility | 26 | $89.45 | $89.46 | $381.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $220.00 / $259.60 / $343.81
| Professional | | $220.00 | $259.60 | $343.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $235.10 / $334.29 / $614.91
| Professional | | $235.10 | $334.29 | $614.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $382.05 / $455.25 / $455.25
| Professional | | $382.05 | $455.25 | $455.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $205.85 / $252.55 / $384.70
| Professional | | $205.85 | $252.55 | $384.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.43 / $313.83 / $570.04
| Professional | | $211.43 | $313.83 | $570.04 |