- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $353.91 / $353.91 / $353.91
| Facility | 26 | $353.91 | $353.91 | $353.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.42 / $132.19 / $152.53
| Professional | | $108.42 | $132.19 | $152.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.55 / $214.86 / $260.79
| Professional | | $169.55 | $214.86 | $260.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.27 / $220.96 / $297.73
| Professional | | $125.27 | $220.96 | $297.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.05 / $181.96 / $301.39
| Professional | | $110.05 | $181.96 | $301.39 |