- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $166.95 / $486.88 / $637.66
| Facility | 26 | $166.95 | $486.88 | $637.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $425.00 / $604.29 / $3,271.06
| Professional | | $425.00 | $604.29 | $3,271.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $460.67 / $1,340.99 / $1,733.36
| Professional | | $460.67 | $1,340.99 | $1,733.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $613.17 / $1,140.97 / $1,626.19
| Professional | | $613.17 | $1,140.97 | $1,626.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $497.00 / $962.07 / $1,159.33
| Professional | | $497.00 | $962.07 | $1,159.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $481.25 / $859.33 / $1,555.31
| Professional | | $481.25 | $859.33 | $1,555.31 |