- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $27.55 / $99.10 / $99.10
| Facility | 26 | $27.55 | $99.10 | $99.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $82.90 / $111.02 / $306.52
| Professional | | $82.90 | $111.02 | $306.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.12 / $186.64 / $263.94
| Professional | | $127.12 | $186.64 | $263.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.50 / $221.77 / $414.29
| Professional | | $142.50 | $221.77 | $414.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.53 / $258.64 / $479.39
| Professional | | $145.53 | $258.64 | $479.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.07 / $159.56 / $292.76
| Professional | | $104.07 | $159.56 | $292.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.58 / $118.76 / $179.36
| Professional | | $94.58 | $118.76 | $179.36 |