- 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
- $370.50 / $447.39 / $755.28
| Professional | | $370.50 | $447.39 | $755.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $377.42 / $785.84 / $1,361.43
| Professional | | $377.42 | $785.84 | $1,361.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $497.00 / $658.08 / $1,653.06
| Professional | | $497.00 | $658.08 | $1,653.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $367.13 / $487.24 / $954.46
| Professional | | $367.13 | $487.24 | $954.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.65 / $681.13 / $1,096.01
| Professional | | $380.65 | $681.13 | $1,096.01 |