- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $72.15 / $72.15 / $123.19
| Facility | 26 | $72.15 | $72.15 | $123.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $369.25 / $467.54 / $559.61
| Professional | | $369.25 | $467.54 | $559.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,049.97 / $1,147.09 / $1,355.30
| Professional | | $1,049.97 | $1,147.09 | $1,355.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $356.52 / $842.96 / $1,288.44
| Professional | | $356.52 | $842.96 | $1,288.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $461.89 / $817.15 / $3,264.77
| Professional | | $461.89 | $817.15 | $3,264.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $461.89 / $788.78 / $1,139.35
| Professional | | $461.89 | $788.78 | $1,139.35 |