- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $228.51 / $228.51 / $228.51
| Facility | 26 | $228.51 | $228.51 | $228.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.37 / $193.95 / $193.95
| Professional | | $167.37 | $193.95 | $193.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $205.55 / $205.55 / $340.68
| Professional | | $205.55 | $205.55 | $340.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $214.11 / $383.31 / $390.85
| Professional | | $214.11 | $383.31 | $390.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.18 / $175.87 / $286.44
| Professional | | $112.18 | $175.87 | $286.44 |