- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $32.97 / $32.97 / $153.08
| Facility | 26 | $32.97 | $32.97 | $153.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.95 / $175.45 / $222.15
| Professional | | $125.95 | $175.45 | $222.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.68 / $210.45 / $364.34
| Professional | | $133.68 | $210.45 | $364.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $238.83 / $238.83 / $238.83
| Professional | | $238.83 | $238.83 | $238.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.16 / $185.54 / $223.01
| Professional | | $150.16 | $185.54 | $223.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.79 / $215.21 / $377.56
| Professional | | $144.79 | $215.21 | $377.56 |