- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $81.53 / $91.49 / $141.86
| Facility | 26 | $81.53 | $91.49 | $141.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $580.30 / $673.33 / $809.22
| Professional | | $580.30 | $673.33 | $809.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $612.97 / $806.19 / $1,350.57
| Professional | | $612.97 | $806.19 | $1,350.57 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $96.65 / $96.65 / $96.65
| Facility | 26 | $96.65 | $96.65 | $96.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $701.19 / $1,006.53 / $1,613.77
| Professional | | $701.19 | $1,006.53 | $1,613.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $623.87 / $797.86 / $1,422.89
| Professional | | $623.87 | $797.86 | $1,422.89 |