- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $68.81 / $68.81 / $68.81
| Facility | 26 | $68.81 | $68.81 | $68.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $202.30 / $301.37 / $301.37
| Professional | | $202.30 | $301.37 | $301.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $156.22 / $243.03 / $286.77
| Professional | | $156.22 | $243.03 | $286.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $68.64 / $121.85 / $1,539.04
| Professional | | $68.64 | $121.85 | $1,539.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.32 / $168.90 / $281.50
| Professional | | $113.32 | $168.90 | $281.50 |