- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $30.20 / $30.20 / $30.20
| Facility | 26 | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $181.97 / $263.03
| Professional | | $141.25 | $181.97 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.88 / $169.82 / $223.87
| Professional | | $154.88 | $169.82 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $208.93 / $416.87
| Professional | | $144.54 | $208.93 | $416.87 |
- 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
- $165.96 / $204.17 / $323.59
| Professional | | $165.96 | $204.17 | $323.59 |