- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $112.12 / $112.12 / $112.12
| Facility | 26 | $112.12 | $112.12 | $112.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $573.67 / $839.09 / $839.09
| Professional | | $573.67 | $839.09 | $839.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $461.36 / $659.08 / $724.99
| Professional | | $461.36 | $659.08 | $724.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $635.77 / $892.87 / $1,179.72
| Professional | | $635.77 | $892.87 | $1,179.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $514.09 / $659.08 / $963.98
| Professional | | $514.09 | $659.08 | $963.98 |