- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $103.54 / $103.54 / $103.54
| Facility | 26 | $103.54 | $103.54 | $103.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.85 / $300.85 / $562.62
| Professional | | $300.85 | $300.85 | $562.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $441.54 / $551.02 / $1,595.84
| Professional | | $441.54 | $551.02 | $1,595.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.86 / $486.93 / $1,595.84
| Professional | | $331.86 | $486.93 | $1,595.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $305.10 / $361.92 / $846.02
| Professional | | $305.10 | $361.92 | $846.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $315.19 / $531.37 / $1,544.73
| Professional | | $315.19 | $531.37 | $1,544.73 |