- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $62.35 / $62.35 / $62.35
| Facility | 26 | $62.35 | $62.35 | $62.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.24 / $201.43 / $305.52
| Professional | | $183.24 | $201.43 | $305.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.75 / $182.06 / $325.16
| Professional | | $154.75 | $182.06 | $325.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.75 / $244.86 / $430.66
| Professional | | $203.75 | $244.86 | $430.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.66 / $235.03 / $358.14
| Professional | | $141.66 | $235.03 | $358.14 |