- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $194.18 / $194.18 / $194.18
| Facility | 26 | $194.18 | $194.18 | $194.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.28 / $187.33 / $223.87
| Professional | | $169.28 | $187.33 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $274.85 / $274.85 / $355.36
| Professional | | $274.85 | $274.85 | $355.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.29 / $395.41 / $537.57
| Professional | | $286.29 | $395.41 | $537.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.30 / $195.58 / $447.04
| Professional | | $144.30 | $195.58 | $447.04 |