- 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
- $289.52 / $576.17 / $600.00
| Professional | | $289.52 | $576.17 | $600.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $351.39 / $387.41 / $948.91
| Professional | | $351.39 | $387.41 | $948.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $304.98 / $558.77 / $785.75
| Professional | | $304.98 | $558.77 | $785.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $306.97 / $508.08 / $688.28
| Professional | | $306.97 | $508.08 | $688.28 |