- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $53.70 / $53.70 / $57.54
| Facility | 26 | $53.70 | $53.70 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $213.80 / $288.40
| Professional | | $169.82 | $213.80 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $416.87 / $467.74
| Professional | | $316.23 | $416.87 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $354.81 / $575.44
| Professional | | $162.18 | $354.81 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.80 / $389.05 / $1,318.26
| Professional | | $213.80 | $389.05 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.80 / $380.19 / $512.86
| Professional | | $213.80 | $380.19 | $512.86 |