- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $61.20 / $61.20 / $61.20
| Facility | 26 | $61.20 | $61.20 | $61.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.06 / $368.53 / $464.96
| Professional | | $286.06 | $368.53 | $464.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.20 / $376.99 / $444.85
| Professional | | $275.20 | $376.99 | $444.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $255.59 / $427.15 / $861.29
| Professional | | $255.59 | $427.15 | $861.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $304.77 / $369.10 / $562.05
| Professional | | $304.77 | $369.10 | $562.05 |