- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $32.10 / $32.10 / $54.11
| Facility | 26 | $32.10 | $32.10 | $54.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $197.20 / $198.09 / $210.25
| Professional | | $197.20 | $198.09 | $210.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.59 / $169.39 / $240.53
| Professional | | $164.59 | $169.39 | $240.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.02 / $191.15 / $248.70
| Professional | | $34.02 | $191.15 | $248.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $187.31 / $245.23 / $456.32
| Professional | | $187.31 | $245.23 | $456.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $178.75 / $242.16 / $415.36
| Professional | | $178.75 | $242.16 | $415.36 |