- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $75.70 / $75.70 / $112.25
| Facility | 26 | $75.70 | $75.70 | $112.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $369.25 / $480.17 / $545.21
| Professional | | $369.25 | $480.17 | $545.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $220.30 / $220.30 / $347.07
| Professional | | $220.30 | $220.30 | $347.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $216.28 / $390.80 / $796.65
| Professional | | $216.28 | $390.80 | $796.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $311.38 / $469.13 / $790.63
| Professional | | $311.38 | $469.13 | $790.63 |