- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $145.25 / $145.25 / $145.25
| Facility | 26 | $145.25 | $145.25 | $145.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $175.22 / $192.76 / $192.76
| Professional | | $175.22 | $192.76 | $192.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $216.67 / $216.67 / $363.64
| Professional | | $216.67 | $216.67 | $363.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $225.70 / $406.03 / $413.90
| Professional | | $225.70 | $406.03 | $413.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.26 / $153.88 / $308.08
| Professional | | $120.26 | $153.88 | $308.08 |