- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $190.55 / $190.55 / $190.55
| Facility | 26 | $190.55 | $190.55 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $194.98 / $707.95
| Professional | | $147.91 | $194.98 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $154.88 / $354.81
| Professional | | $131.83 | $154.88 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.80 / $380.19 / $398.11
| Professional | | $213.80 | $380.19 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $177.83 / $288.40
| Professional | | $112.20 | $177.83 | $288.40 |