- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $21.89 / $21.89 / $22.30
| Facility | 26 | $21.89 | $21.89 | $22.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.04 / $174.04 / $192.43
| Professional | | $174.04 | $174.04 | $192.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $471.00 / $471.00 / $774.00
| Professional | | $471.00 | $471.00 | $774.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $262.20 / $262.20 / $542.98
| Professional | | $262.20 | $262.20 | $542.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.81 / $346.58 / $605.22
| Professional | | $167.81 | $346.58 | $605.22 |