- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $328.21 / $328.21 / $328.21
| Facility | 26 | $328.21 | $328.21 | $328.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.71 / $209.05 / $250.90
| Professional | | $126.71 | $209.05 | $250.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.94 / $180.41 / $348.70
| Professional | | $155.94 | $180.41 | $348.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.77 / $263.54 / $403.67
| Professional | | $145.77 | $263.54 | $403.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.65 / $243.46 / $516.28
| Professional | | $151.65 | $243.46 | $516.28 |