- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $353.11 / $353.11 / $353.11
| Facility | 26 | $353.11 | $353.11 | $353.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $313.31 / $343.61 / $412.45
| Professional | | $313.31 | $343.61 | $412.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $391.42 / $536.99 / $893.50
| Professional | | $391.42 | $536.99 | $893.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $559.36 / $955.72 / $1,276.07
| Professional | | $559.36 | $955.72 | $1,276.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.52 / $474.58 / $794.78
| Professional | | $234.52 | $474.58 | $794.78 |