- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $110.00 / $120.00 / $232.25
| Facility | 26 | $110.00 | $120.00 | $232.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $378.96 / $550.00 / $913.16
| Professional | | $378.96 | $550.00 | $913.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $580.72 / $707.69 / $914.53
| Professional | | $580.72 | $707.69 | $914.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.16 / $488.73 / $1,063.48
| Professional | | $263.16 | $488.73 | $1,063.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $374.19 / $581.04 / $1,071.95
| Professional | | $374.19 | $581.04 | $1,071.95 |