- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $27.21 / $27.22 / $27.22
| Facility | 26 | $27.21 | $27.22 | $27.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.90 / $226.83 / $226.83
| Professional | | $154.90 | $226.83 | $226.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.20 / $178.85 / $196.74
| Professional | | $125.20 | $178.85 | $196.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.83 / $248.76 / $1,013.79
| Professional | | $186.83 | $248.76 | $1,013.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.09 / $176.48 / $222.06
| Professional | | $119.09 | $176.48 | $222.06 |