- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $298.77 / $298.77 / $298.77
| Facility | 26 | $298.77 | $298.77 | $298.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $392.93 / $396.79 / $486.85
| Professional | | $392.93 | $396.79 | $486.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $406.81 / $478.60 / $1,075.39
| Professional | | $406.81 | $478.60 | $1,075.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $373.21 / $631.12 / $930.51
| Professional | | $373.21 | $631.12 | $930.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $437.97 / $557.84 / $889.50
| Professional | | $437.97 | $557.84 | $889.50 |