- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $34.83 / $37.11 / $44.53
| Facility | 26 | $34.83 | $37.11 | $44.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.16 / $125.37 / $152.72
| Professional | | $102.16 | $125.37 | $152.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.58 / $149.00 / $165.56
| Professional | | $112.58 | $149.00 | $165.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.44 / $149.54 / $224.66
| Professional | | $102.44 | $149.54 | $224.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.32 / $136.72 / $237.65
| Professional | | $100.32 | $136.72 | $237.65 |