- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $277.67 / $277.67 / $277.67
| Facility | 26 | $277.67 | $277.67 | $277.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $76.06 / $110.25 / $145.18
| Professional | | $76.06 | $110.25 | $145.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.58 / $138.91 / $259.35
| Professional | | $128.58 | $138.91 | $259.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.18 / $182.03 / $277.75
| Professional | | $101.18 | $182.03 | $277.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.32 / $159.97 / $268.52
| Professional | | $113.32 | $159.97 | $268.52 |