- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $134.18 / $134.18 / $134.18
| Facility | 26 | $134.18 | $134.18 | $134.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $358.90 / $392.05 / $491.51
| Professional | | $358.90 | $392.05 | $491.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.67 / $395.44 / $466.62
| Professional | | $288.67 | $395.44 | $466.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.69 / $460.17 / $1,550.86
| Professional | | $263.69 | $460.17 | $1,550.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $247.75 / $358.26 / $517.49
| Professional | | $247.75 | $358.26 | $517.49 |