- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $123.97 / $123.97 / $123.97
| Facility | 26 | $123.97 | $123.97 | $123.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.44 / $389.80 / $389.80
| Professional | | $186.44 | $389.80 | $389.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.44 / $222.54 / $262.60
| Professional | | $162.44 | $222.54 | $262.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.65 / $223.97 / $593.55
| Professional | | $184.65 | $223.97 | $593.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.87 / $207.08 / $255.48
| Professional | | $155.87 | $207.08 | $255.48 |