- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $43.47 / $43.47 / $44.26
| Facility | 26 | $43.47 | $43.47 | $44.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $276.58 / $304.01 / $483.12
| Professional | | $276.58 | $304.01 | $483.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $931.00 / $1,530.00 / $1,530.00
| Professional | | $931.00 | $1,530.00 | $1,530.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $386.19 / $597.35 / $1,068.11
| Professional | | $386.19 | $597.35 | $1,068.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $335.88 / $713.66 / $1,279.29
| Professional | | $335.88 | $713.66 | $1,279.29 |