- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $66.07 / $66.07 / $66.07
| Facility | 26 | $66.07 | $66.07 | $66.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $147.91 / $199.53
| Professional | | $114.82 | $147.91 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $151.36 / $512.86
| Professional | | $151.36 | $151.36 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $177.83 / $323.59
| Professional | | $107.15 | $177.83 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.88 / $181.97 / $512.86
| Professional | | $154.88 | $181.97 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $204.17 / $588.84
| Professional | | $131.83 | $204.17 | $588.84 |