- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $211.71 / $211.71 / $211.71
| Facility | 26 | $211.71 | $211.71 | $211.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.00 / $652.22 / $784.33
| Professional | | $275.00 | $652.22 | $784.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.58 / $263.07 / $564.38
| Professional | | $174.58 | $263.07 | $564.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $357.67 / $605.65 / $1,266.43
| Professional | | $357.67 | $605.65 | $1,266.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.04 / $546.95 / $1,118.34
| Professional | | $389.04 | $546.95 | $1,118.34 |