- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $133.96 / $133.96 / $136.44
| Facility | 26 | $133.96 | $133.96 | $136.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $447.39 / $475.00 / $711.31
| Professional | | $447.39 | $475.00 | $711.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,130.00 / $1,856.00 / $3,430.00
| Professional | | $1,130.00 | $1,856.00 | $3,430.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $641.63 / $905.96 / $1,560.75
| Professional | | $641.63 | $905.96 | $1,560.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $629.29 / $975.14 / $2,253.91
| Professional | | $629.29 | $975.14 | $2,253.91 |