- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $451.43 / $451.43 / $451.43
| Facility | 26 | $451.43 | $451.43 | $451.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $244.16 / $341.22 / $398.49
| Professional | | $244.16 | $341.22 | $398.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $396.52 / $444.00 / $751.34
| Professional | | $396.52 | $444.00 | $751.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $462.50 / $737.16 / $1,043.49
| Professional | | $462.50 | $737.16 | $1,043.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $319.23 / $459.77 / $613.02
| Professional | | $319.23 | $459.77 | $613.02 |