- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $86.07 / $189.45 / $189.45
| Facility | 26 | $86.07 | $189.45 | $189.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.74 / $337.19 / $962.96
| Professional | | $300.74 | $337.19 | $962.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $431.50 / $612.84 / $888.61
| Professional | | $431.50 | $612.84 | $888.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $566.83 / $918.44 / $1,356.73
| Professional | | $566.83 | $918.44 | $1,356.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $494.18 / $941.13 / $1,627.22
| Professional | | $494.18 | $941.13 | $1,627.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $317.48 / $591.32 / $1,036.90
| Professional | | $317.48 | $591.32 | $1,036.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $378.24 / $416.06 / $529.54
| Professional | | $378.24 | $416.06 | $529.54 |