- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $102.36 / $102.36 / $102.36
| Facility | 26 | $102.36 | $102.36 | $102.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $280.77 / $370.50 / $425.00
| Professional | | $280.77 | $370.50 | $425.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.63 / $445.76 / $639.16
| Professional | | $208.63 | $445.76 | $639.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $277.92 / $466.47 / $680.66
| Professional | | $277.92 | $466.47 | $680.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $238.84 / $424.47 / $786.76
| Professional | | $238.84 | $424.47 | $786.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $308.51 / $397.20 / $1,499.16
| Professional | | $308.51 | $397.20 | $1,499.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $267.95 / $294.76 / $375.14
| Professional | | $267.95 | $294.76 | $375.14 |