- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $176.20 / $176.20 / $176.20
| Facility | 26 | $176.20 | $176.20 | $176.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.32 / $450.47 / $818.63
| Professional | | $346.32 | $450.47 | $818.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.42 / $404.69 / $482.78
| Professional | | $295.42 | $404.69 | $482.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.99 / $289.44 / $765.84
| Professional | | $198.99 | $289.44 | $765.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $237.62 / $326.39 / $559.16
| Professional | | $237.62 | $326.39 | $559.16 |