- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $35.88 / $61.77 / $78.78
| Facility | 26 | $35.88 | $61.77 | $78.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $59.73 / $103.96 / $176.90
| Professional | | $59.73 | $103.96 | $176.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $254.00 / $254.00 / $254.00
| Professional | | $254.00 | $254.00 | $254.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.27 / $175.36 / $273.91
| Professional | | $57.27 | $175.36 | $273.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.52 / $32.34 / $32.34
| Professional | | $31.52 | $32.34 | $32.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $82.48 / $113.98 / $234.11
| Professional | | $82.48 | $113.98 | $234.11 |