- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $68.88 / $78.29 / $93.60
| Facility | 26 | $68.88 | $78.29 | $93.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.44 / $209.05 / $423.26
| Professional | | $123.44 | $209.05 | $423.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.72 / $216.69 / $240.77
| Professional | | $163.72 | $216.69 | $240.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.91 / $258.68 / $819.89
| Professional | | $130.91 | $258.68 | $819.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.63 / $233.38 / $632.53
| Professional | | $142.63 | $233.38 | $632.53 |