- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $78.20 / $110.00 / $127.98
| Facility | 26 | $78.20 | $110.00 | $127.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $252.41 / $550.00 / $603.53
| Professional | | $252.41 | $550.00 | $603.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $422.10 / $486.61 / $621.89
| Professional | | $422.10 | $486.61 | $621.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $196.04 / $364.59 / $690.57
| Professional | | $196.04 | $364.59 | $690.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.27 / $426.58 / $730.12
| Professional | | $286.27 | $426.58 | $730.12 |