- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $119.20 / $119.21 / $518.49
| Facility | 26 | $119.20 | $119.21 | $518.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $289.05 / $425.00 / $598.40
| Professional | | $289.05 | $425.00 | $598.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $237.60 / $493.18 / $827.96
| Professional | | $237.60 | $493.18 | $827.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $327.02 / $432.37 / $1,087.18
| Professional | | $327.02 | $432.37 | $1,087.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $265.32 / $312.14 / $550.73
| Professional | | $265.32 | $312.14 | $550.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $261.16 / $426.92 / $696.72
| Professional | | $261.16 | $426.92 | $696.72 |