- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $112.58 / $112.58 / $112.58
| Facility | 26 | $112.58 | $112.58 | $112.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $179.57 / $193.61 / $237.08
| Professional | | $179.57 | $193.61 | $237.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.70 / $317.93 / $857.92
| Professional | | $269.70 | $317.93 | $857.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.72 / $321.07 / $857.92
| Professional | | $181.72 | $321.07 | $857.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.42 / $325.51 / $568.58
| Professional | | $211.42 | $325.51 | $568.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $230.80 / $357.11 / $1,038.15
| Professional | | $230.80 | $357.11 | $1,038.15 |