- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $63.10 / $63.10 / $63.10
| Facility | 26 | $63.10 | $63.10 | $63.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $141.25 / $194.98
| Professional | | $107.15 | $141.25 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $162.18 / $234.42
| Professional | | $123.03 | $162.18 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $147.91 / $239.88
| Professional | | $102.33 | $147.91 | $239.88 |
- 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
- $93.33 / $134.90 / $218.78
| Professional | | $93.33 | $134.90 | $218.78 |