- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $53.10 / $53.10 / $53.10
| Facility | 26 | $53.10 | $53.10 | $53.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $255.03 / $357.48 / $373.03
| Professional | | $255.03 | $357.48 | $373.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $230.86 / $329.80 / $362.78
| Professional | | $230.86 | $329.80 | $362.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $311.48 / $443.12 / $1,691.60
| Professional | | $311.48 | $443.12 | $1,691.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.72 / $290.39 / $388.03
| Professional | | $203.72 | $290.39 | $388.03 |