- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $40.86 / $98.37 / $98.37
| Facility | 26 | $40.86 | $98.37 | $98.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.84 / $105.80 / $145.93
| Professional | | $77.84 | $105.80 | $145.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.65 / $177.14 / $250.51
| Professional | | $120.65 | $177.14 | $250.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.13 / $223.00 / $392.69
| Professional | | $149.13 | $223.00 | $392.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.12 / $245.47 / $454.98
| Professional | | $138.12 | $245.47 | $454.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.53 / $175.25 / $591.59
| Professional | | $122.53 | $175.25 | $591.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.03 / $113.33 / $144.24
| Professional | | $103.03 | $113.33 | $144.24 |