- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $27.78 / $27.78 / $27.78
| Facility | 26 | $27.78 | $27.78 | $27.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.02 / $160.56 / $238.69
| Professional | | $124.02 | $160.56 | $238.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $270.85 / $325.66 / $392.09
| Professional | | $270.85 | $325.66 | $392.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.50 / $302.32 / $472.42
| Professional | | $124.50 | $302.32 | $472.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.69 / $247.56 / $1,025.66
| Professional | | $135.69 | $247.56 | $1,025.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.69 / $247.56 / $323.20
| Professional | | $135.69 | $247.56 | $323.20 |