- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $37.04 / $37.04 / $37.70
| Facility | 26 | $37.04 | $37.04 | $37.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $270.70 / $270.70 / $306.81
| Professional | | $270.70 | $270.70 | $306.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $743.00 / $743.00 / $1,221.00
| Professional | | $743.00 | $743.00 | $1,221.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $420.80 / $420.80 / $869.50
| Professional | | $420.80 | $420.80 | $869.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $274.57 / $555.52 / $970.08
| Professional | | $274.57 | $555.52 | $970.08 |