- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $117.49 / $117.49 / $117.49
| Facility | 26 | $117.49 | $117.49 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $190.55 / $660.69
| Professional | | $162.18 | $190.55 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $162.18 / $380.19
| Professional | | $138.04 | $162.18 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $407.38 / $426.58
| Professional | | $223.87 | $407.38 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $165.96 / $309.03
| Professional | | $120.23 | $165.96 | $309.03 |