- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $52.80 / $52.80 / $53.75
| Facility | 26 | $52.80 | $52.80 | $53.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $320.67 / $320.67 / $320.67
| Professional | | $320.67 | $320.67 | $320.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $843.00 / $843.00 / $1,384.00
| Professional | | $843.00 | $843.00 | $1,384.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $481.17 / $481.17 / $992.96
| Professional | | $481.17 | $481.17 | $992.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.57 / $629.29 / $1,098.93
| Professional | | $309.57 | $629.29 | $1,098.93 |