- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $68.97 / $68.97 / $70.62
| Facility | 26 | $68.97 | $68.97 | $70.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $521.66 / $521.66 / $527.34
| Professional | | $521.66 | $521.66 | $527.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,352.00 / $2,222.00 / $2,222.00
| Professional | | $1,352.00 | $2,222.00 | $2,222.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $526.36 / $556.41 / $1,661.60
| Professional | | $526.36 | $556.41 | $1,661.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $403.12 / $790.20 / $1,355.88
| Professional | | $403.12 | $790.20 | $1,355.88 |