- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $41.04 / $41.04 / $69.17
| Facility | 26 | $41.04 | $41.04 | $69.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $193.59 / $195.47 / $207.56
| Professional | | $193.59 | $195.47 | $207.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $191.27 / $220.12 / $312.57
| Professional | | $191.27 | $220.12 | $312.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.49 / $165.13 / $248.65
| Professional | | $43.49 | $165.13 | $248.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $231.71 / $289.45 / $527.64
| Professional | | $231.71 | $289.45 | $527.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $205.46 / $242.63 / $397.51
| Professional | | $205.46 | $242.63 | $397.51 |