- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $339.08 / $339.08 / $339.08
| Facility | 26 | $339.08 | $339.08 | $339.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.37 / $192.40 / $214.37
| Professional | | $112.37 | $192.40 | $214.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.49 / $157.65 / $308.72
| Professional | | $139.49 | $157.65 | $308.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.96 / $232.62 / $355.89
| Professional | | $127.96 | $232.62 | $355.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.34 / $233.65 / $569.48
| Professional | | $144.34 | $233.65 | $569.48 |