- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $120.74 / $120.74 / $203.25
| Facility | 26 | $120.74 | $120.74 | $203.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $175.41 / $262.27 / $441.51
| Professional | | $175.41 | $262.27 | $441.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $330.00 / $330.00 / $330.00
| Professional | | $330.00 | $330.00 | $330.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $210.22 / $296.48 / $417.23
| Professional | | $210.22 | $296.48 | $417.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $173.05
| Professional | | $32.34 | $32.34 | $173.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $196.83 / $240.24 / $450.20
| Professional | | $196.83 | $240.24 | $450.20 |