- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $275.85 / $275.85 / $464.35
| Facility | 26 | $275.85 | $275.85 | $464.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $261.56 / $324.04 / $545.46
| Professional | | $261.56 | $324.04 | $545.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $375.00 / $375.00 / $375.00
| Professional | | $375.00 | $375.00 | $375.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $272.12 / $413.16 / $512.23
| Professional | | $272.12 | $413.16 | $512.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $32.34
| Professional | | $32.34 | $32.34 | $32.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $233.12 / $321.45 / $530.99
| Professional | | $233.12 | $321.45 | $530.99 |