- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $41.18 / $41.18 / $41.18
| Facility | 26 | $41.18 | $41.18 | $41.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.28 / $301.77 / $301.77
| Professional | | $169.28 | $301.77 | $301.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.62 / $239.46 / $263.41
| Professional | | $167.62 | $239.46 | $263.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.88 / $290.66 / $1,035.10
| Professional | | $190.88 | $290.66 | $1,035.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.82 / $221.66 / $293.77
| Professional | | $155.82 | $221.66 | $293.77 |