- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $43.10 / $43.10 / $43.10
| Facility | 26 | $43.10 | $43.10 | $43.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.19 / $108.96 / $145.86
| Professional | | $84.19 | $108.96 | $145.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.33 / $240.58 / $264.64
| Professional | | $198.33 | $240.58 | $264.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.47 / $221.60 / $346.30
| Professional | | $85.47 | $221.60 | $346.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.07 / $185.29 / $706.46
| Professional | | $110.07 | $185.29 | $706.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.07 / $195.04 / $260.25
| Professional | | $110.07 | $195.04 | $260.25 |