- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $150.09 / $150.09 / $150.09
| Facility | 26 | $150.09 | $150.09 | $150.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $370.50 / $443.16 / $577.65
| Professional | | $370.50 | $443.16 | $577.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $330.58 / $706.30 / $1,012.76
| Professional | | $330.58 | $706.30 | $1,012.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $440.51 / $741.53 / $1,056.83
| Professional | | $440.51 | $741.53 | $1,056.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $378.45 / $672.58 / $1,246.65
| Professional | | $378.45 | $672.58 | $1,246.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.13 / $591.69 / $1,544.61
| Professional | | $489.13 | $591.69 | $1,544.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $361.54 / $422.28 / $637.76
| Professional | | $361.54 | $422.28 | $637.76 |