- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $161.04 / $161.04 / $241.56
| Facility | 26 | $161.04 | $161.04 | $241.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $580.33 / $842.90 / $912.20
| Professional | | $580.33 | $842.90 | $912.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $787.58 / $1,042.38 / $1,042.38
| Professional | | $787.58 | $1,042.38 | $1,042.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,077.83 / $1,262.84 / $1,857.36
| Professional | | $1,077.83 | $1,262.84 | $1,857.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $736.77 / $987.85 / $1,544.33
| Professional | | $736.77 | $987.85 | $1,544.33 |