- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $313.38 / $313.38 / $313.38
| Facility | 26 | $313.38 | $313.38 | $313.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.41 / $138.53 / $153.78
| Professional | | $107.41 | $138.53 | $153.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.74 / $165.29 / $315.51
| Professional | | $147.74 | $165.29 | $315.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.34 / $200.84 / $285.52
| Professional | | $124.34 | $200.84 | $285.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.79 / $160.33 / $253.97
| Professional | | $97.79 | $160.33 | $253.97 |