- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $55.63 / $55.63 / $55.63
| Facility | 26 | $55.63 | $55.63 | $55.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $175.06 / $183.24 / $202.93
| Professional | | $175.06 | $183.24 | $202.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.45 / $303.49 / $709.80
| Professional | | $257.45 | $303.49 | $709.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.31 / $263.38 / $709.80
| Professional | | $152.31 | $263.38 | $709.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.64 / $276.54 / $478.95
| Professional | | $168.64 | $276.54 | $478.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $179.24 / $276.44 / $871.20
| Professional | | $179.24 | $276.44 | $871.20 |