- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $38.06 / $38.06 / $61.45
| Facility | 26 | $38.06 | $38.06 | $61.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.97 / $184.63 / $215.86
| Professional | | $149.97 | $184.63 | $215.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $326.76 / $396.06 / $435.68
| Professional | | $326.76 | $396.06 | $435.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.57 / $312.57 / $416.37
| Professional | | $184.57 | $312.57 | $416.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $191.27 / $358.87 / $1,153.97
| Professional | | $191.27 | $358.87 | $1,153.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $207.77 / $339.98 / $478.76
| Professional | | $207.77 | $339.98 | $478.76 |