- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $487.03 / $487.03 / $487.03
| Facility | 26 | $487.03 | $487.03 | $487.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.41 / $522.79 / $600.00
| Professional | | $323.41 | $522.79 | $600.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $365.67 / $465.89 / $884.57
| Professional | | $365.67 | $465.89 | $884.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $320.79 / $673.61 / $758.71
| Professional | | $320.79 | $673.61 | $758.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $377.50 / $480.02 / $669.46
| Professional | | $377.50 | $480.02 | $669.46 |