- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $33.11 / $63.10 / $131.83
| Facility | 26 | $33.11 | $63.10 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.10 / $117.49 / $223.87
| Professional | | $87.10 | $117.49 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.50 / $134.90 / $245.47
| Professional | | $95.50 | $134.90 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.72 / $158.49 / $295.12
| Professional | | $97.72 | $158.49 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.90 / $173.78 / $380.19
| Professional | | $134.90 | $173.78 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $28.84 / $38.02 / $97.72
| Professional | 26 | $28.84 | $38.02 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $123.03 / $218.78
| Professional | | $30.20 | $123.03 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $138.04 / $263.03
| Professional | | $104.71 | $138.04 | $263.03 |