- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $167.10 / $167.10 / $167.10
| Facility | 26 | $167.10 | $167.10 | $167.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $171.00 / $328.00 / $397.10
| Professional | | $171.00 | $328.00 | $397.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.99 / $275.74 / $591.58
| Professional | | $182.99 | $275.74 | $591.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $348.06 / $565.25 / $1,400.88
| Professional | | $348.06 | $565.25 | $1,400.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $381.72 / $496.62 / $711.23
| Professional | | $381.72 | $496.62 | $711.23 |