- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $34.82 / $34.82 / $167.23
| Facility | 26 | $34.82 | $34.82 | $167.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $212.30 / $289.41 / $370.00
| Professional | | $212.30 | $289.41 | $370.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $236.11 / $368.21 / $607.41
| Professional | | $236.11 | $368.21 | $607.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $392.96 / $392.96 / $392.96
| Professional | | $392.96 | $392.96 | $392.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $267.95 / $315.24 / $463.88
| Professional | | $267.95 | $315.24 | $463.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $241.72 / $355.70 / $628.54
| Professional | | $241.72 | $355.70 | $628.54 |