- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $531.59 / $531.59 / $531.59
| Facility | 26 | $531.59 | $531.59 | $531.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $626.84 / $722.34 / $722.34
| Professional | | $626.84 | $722.34 | $722.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $762.16 / $762.16 / $1,402.19
| Professional | | $762.16 | $762.16 | $1,402.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $793.91 / $1,445.78 / $1,483.26
| Professional | | $793.91 | $1,445.78 | $1,483.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.89 / $734.42 / $1,104.07
| Professional | | $537.89 | $734.42 | $1,104.07 |