- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $157.91 / $157.91 / $157.91
| Facility | 26 | $157.91 | $157.91 | $157.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.59 / $188.81 / $197.64
| Professional | | $181.59 | $188.81 | $197.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $216.46 / $258.95 / $719.26
| Professional | | $216.46 | $258.95 | $719.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.97 / $263.18 / $719.26
| Professional | | $157.97 | $263.18 | $719.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.57 / $263.18 / $452.30
| Professional | | $170.57 | $263.18 | $452.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.66 / $261.07 / $825.86
| Professional | | $153.66 | $261.07 | $825.86 |