- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $283.94 / $283.94 / $283.94
| Facility | 26 | $283.94 | $283.94 | $283.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $207.56 / $237.76 / $237.76
| Professional | | $207.56 | $237.76 | $237.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $255.79 / $255.79 / $431.67
| Professional | | $255.79 | $255.79 | $431.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $266.45 / $479.65 / $486.47
| Professional | | $266.45 | $479.65 | $486.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $175.74 / $225.65 / $401.70
| Professional | | $175.74 | $225.65 | $401.70 |