- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $60.88 / $60.88 / $91.32
| Facility | 26 | $60.88 | $60.88 | $91.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.50 / $455.14 / $455.14
| Professional | | $263.50 | $455.14 | $455.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $370.55 / $490.43 / $544.91
| Professional | | $370.55 | $490.43 | $544.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $339.22 / $512.23 / $690.24
| Professional | | $339.22 | $512.23 | $690.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $353.54 / $447.01 / $706.19
| Professional | | $353.54 | $447.01 | $706.19 |