- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $72.44 / $72.44 / $134.90
| Facility | 26 | $72.44 | $72.44 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $138.04 / $380.19
| Professional | | $112.20 | $138.04 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $245.47 / $245.47
| Professional | | $245.47 | $245.47 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $199.53 / $275.42
| Professional | | $112.20 | $199.53 | $275.42 |
- 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
- $107.15 / $151.36 / $323.59
| Professional | | $107.15 | $151.36 | $323.59 |