- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $336.43 / $336.43 / $336.43
| Facility | 26 | $336.43 | $336.43 | $336.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.29 / $188.50 / $209.93
| Professional | | $107.29 | $188.50 | $209.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.68 / $146.15 / $304.61
| Professional | | $132.68 | $146.15 | $304.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.05 / $219.95 / $335.17
| Professional | | $119.05 | $219.95 | $335.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.16 / $195.78 / $568.37
| Professional | | $133.16 | $195.78 | $568.37 |