- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $58.11 / $58.11 / $97.83
| Facility | 26 | $58.11 | $58.11 | $97.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.20 / $121.40 / $209.54
| Professional | | $90.20 | $121.40 | $209.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.00 / $144.00 / $144.00
| Professional | | $144.00 | $144.00 | $144.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.25 / $144.47 / $210.87
| Professional | | $103.25 | $144.47 | $210.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $86.11
| Professional | | $32.34 | $32.34 | $86.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $99.86 / $117.83 / $196.94
| Professional | | $99.86 | $117.83 | $196.94 |