- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $104.26 / $104.26 / $243.66
| Facility | 26 | $104.26 | $104.26 | $243.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.31 / $463.23 / $463.23
| Professional | | $257.31 | $463.23 | $463.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.70 / $317.07 / $547.26
| Professional | | $84.70 | $317.07 | $547.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $439.57 / $714.30 / $1,052.42
| Professional | | $439.57 | $714.30 | $1,052.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $117.28 / $459.08
| Professional | | $32.34 | $117.28 | $459.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $476.82 / $892.80 / $1,186.18
| Professional | | $476.82 | $892.80 | $1,186.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $388.42 / $539.29 / $1,158.30
| Professional | | $388.42 | $539.29 | $1,158.30 |