- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $95.58 / $130.41 / $130.41
| Facility | 26 | $95.58 | $130.41 | $130.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $310.89 / $475.00 / $572.90
| Professional | | $310.89 | $475.00 | $572.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $277.91 / $461.55 / $696.00
| Professional | | $277.91 | $461.55 | $696.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $340.74 / $340.74 / $340.74
| Professional | | $340.74 | $340.74 | $340.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $321.29 / $733.38 / $1,010.06
| Professional | | $321.29 | $733.38 | $1,010.06 |