- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $332.58 / $332.58 / $332.58
| Facility | 26 | $332.58 | $332.58 | $332.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.16 / $194.41 / $216.62
| Professional | | $108.16 | $194.41 | $216.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.16 / $149.94 / $307.97
| Professional | | $134.16 | $149.94 | $307.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.02 / $221.97 / $338.94
| Professional | | $122.02 | $221.97 | $338.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.66 / $209.80 / $569.54
| Professional | | $136.66 | $209.80 | $569.54 |