- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $21.59 / $37.17 / $47.41
| Facility | 26 | $21.59 | $37.17 | $47.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.30 / $188.01 / $353.27
| Professional | | $152.30 | $188.01 | $353.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.00 / $243.00 / $243.00
| Professional | | $243.00 | $243.00 | $243.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.07 / $223.77 / $320.01
| Professional | | $139.07 | $223.77 | $320.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $32.34
| Professional | | $32.34 | $32.34 | $32.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.19 / $207.08 / $302.75
| Professional | | $127.19 | $207.08 | $302.75 |