- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $173.29 / $173.29 / $291.70
| Facility | 26 | $173.29 | $173.29 | $291.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $188.57 / $226.18 / $399.89
| Professional | | $188.57 | $226.18 | $399.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $254.00 / $254.00 / $254.00
| Professional | | $254.00 | $254.00 | $254.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.13 / $262.66 / $347.46
| Professional | | $176.13 | $262.66 | $347.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $147.91
| Professional | | $32.34 | $32.34 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.76 / $204.27 / $343.92
| Professional | | $165.76 | $204.27 | $343.92 |