- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $533.89 / $533.89 / $533.89
| Facility | 26 | $533.89 | $533.89 | $533.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.88 / $127.84 / $140.49
| Professional | | $91.88 | $127.84 | $140.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.85 / $161.29 / $248.40
| Professional | | $147.85 | $161.29 | $248.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.01 / $281.99 / $376.65
| Professional | | $168.01 | $281.99 | $376.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.33 / $178.42 / $234.51
| Professional | | $137.33 | $178.42 | $234.51 |