- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $890.85 / $890.85 / $890.85
| Facility | 26 | $890.85 | $890.85 | $890.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $465.01 / $600.00 / $754.50
| Professional | | $465.01 | $600.00 | $754.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $526.14 / $618.99 / $1,135.70
| Professional | | $526.14 | $618.99 | $1,135.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $428.98 / $899.50 / $1,064.55
| Professional | | $428.98 | $899.50 | $1,064.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $505.25 / $721.79 / $1,007.78
| Professional | | $505.25 | $721.79 | $1,007.78 |