- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $46.65 / $46.66 / $46.66
| Facility | 26 | $46.65 | $46.66 | $46.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.63 / $237.41 / $281.95
| Professional | | $192.63 | $237.41 | $281.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.34 / $226.20 / $248.82
| Professional | | $158.34 | $226.20 | $248.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $238.88 / $303.80 / $1,297.51
| Professional | | $238.88 | $303.80 | $1,297.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.59 / $209.69 / $292.01
| Professional | | $145.59 | $209.69 | $292.01 |