- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $113.93 / $233.24 / $314.87
| Facility | 26 | $113.93 | $233.24 | $314.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.58 / $1,491.25 / $1,536.89
| Professional | | $741.58 | $1,491.25 | $1,536.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $613.48 / $840.38 / $991.65
| Professional | | $613.48 | $840.38 | $991.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.94 / $995.73 / $2,346.67
| Professional | | $776.94 | $995.73 | $2,346.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $625.12 / $820.79 / $1,270.07
| Professional | | $625.12 | $820.79 | $1,270.07 |