- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $434.36 / $434.36 / $434.36
| Facility | 26 | $434.36 | $434.36 | $434.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $321.72 / $413.21 / $495.85
| Professional | | $321.72 | $413.21 | $495.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $563.69 / $656.65 / $838.94
| Professional | | $563.69 | $656.65 | $838.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $684.02 / $956.56 / $1,527.79
| Professional | | $684.02 | $956.56 | $1,527.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.96 / $596.60 / $795.47
| Professional | | $172.96 | $596.60 | $795.47 |