- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $19.05 / $19.05 / $33.11
| Facility | 26 | $19.05 | $19.05 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $169.82 / $263.03
| Professional | | $151.36 | $169.82 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $257.04 / $257.04
| Professional | | $257.04 | $257.04 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $234.42 / $407.38
| Professional | | $151.36 | $234.42 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $32.36 / $33.11
| Professional | | $32.36 | $32.36 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $181.97 / $269.15
| Professional | | $125.89 | $181.97 | $269.15 |