- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $74.13 / $263.03 / $302.00
| Facility | 26 | $74.13 | $263.03 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $199.53 / $354.81
| Professional | | $169.82 | $199.53 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.96 / $269.15 / $478.63
| Professional | | $165.96 | $269.15 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.96 / $288.40 / $645.65
| Professional | | $165.96 | $288.40 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $281.84 / $407.38
| Professional | | $204.17 | $281.84 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $257.04 / $524.81
| Professional | | $177.83 | $257.04 | $524.81 |