- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $73.40 / $73.40 / $74.79
| Facility | 26 | $73.40 | $73.40 | $74.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $278.80 / $442.33 / $475.00
| Professional | | $278.80 | $442.33 | $475.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $719.00 / $1,180.00 / $2,181.00
| Professional | | $719.00 | $1,180.00 | $2,181.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $439.46 / $576.69 / $1,099.51
| Professional | | $439.46 | $576.69 | $1,099.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $476.81 / $607.37 / $1,648.89
| Professional | | $476.81 | $607.37 | $1,648.89 |