- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $209.73 / $595.28 / $595.28
| Facility | 26 | $209.73 | $595.28 | $595.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $370.50 / $425.00 / $1,459.50
| Professional | | $370.50 | $425.00 | $1,459.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $413.06 / $882.53 / $1,248.07
| Professional | | $413.06 | $882.53 | $1,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $568.26 / $995.54 / $1,821.66
| Professional | | $568.26 | $995.54 | $1,821.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $472.87 / $840.38 / $1,557.68
| Professional | | $472.87 | $840.38 | $1,557.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $555.78 / $756.41 / $1,394.66
| Professional | | $555.78 | $756.41 | $1,394.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $553.54 / $664.26 / $976.46
| Professional | | $553.54 | $664.26 | $976.46 |