- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $58.62 / $58.62 / $97.85
| Facility | 26 | $58.62 | $58.62 | $97.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.74 / $467.69 / $763.60
| Professional | | $300.74 | $467.69 | $763.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $858.25 / $928.20 / $1,096.68
| Professional | | $858.25 | $928.20 | $1,096.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $441.15 / $708.50 / $1,055.73
| Professional | | $441.15 | $708.50 | $1,055.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $450.85 / $842.63 / $3,514.00
| Professional | | $450.85 | $842.63 | $3,514.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $474.58 / $798.28 / $1,193.49
| Professional | | $474.58 | $798.28 | $1,193.49 |