- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $493.35 / $493.35 / $493.35
| Facility | 26 | $493.35 | $493.35 | $493.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $296.17 / $573.58 / $600.00
| Professional | | $296.17 | $573.58 | $600.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $335.10 / $394.23 / $922.08
| Professional | | $335.10 | $394.23 | $922.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $303.62 / $574.70 / $804.23
| Professional | | $303.62 | $574.70 | $804.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $328.02 / $458.85 / $755.43
| Professional | | $328.02 | $458.85 | $755.43 |