- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $204.17 / $204.17 / $204.17
| Facility | 26 | $204.17 | $204.17 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $316.23 / $1,148.15
| Professional | | $257.04 | $316.23 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.80 / $251.19 / $616.60
| Professional | | $213.80 | $251.19 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $645.65 / $676.08
| Professional | | $354.81 | $645.65 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $281.84 / $501.19
| Professional | | $223.87 | $281.84 | $501.19 |