- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $87.82 / $87.82 / $87.82
| Facility | 26 | $87.82 | $87.82 | $87.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $303.80 / $435.22 / $685.28
| Professional | | $303.80 | $435.22 | $685.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $760.46 / $914.35 / $1,087.56
| Professional | | $760.46 | $914.35 | $1,087.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $319.39 / $860.27 / $1,293.34
| Professional | | $319.39 | $860.27 | $1,293.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $313.02 / $526.10 / $3,193.76
| Professional | | $313.02 | $526.10 | $3,193.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $307.19 / $499.80 / $982.88
| Professional | | $307.19 | $499.80 | $982.88 |