- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $55.44 / $66.83 / $90.46
| Facility | 26 | $55.44 | $66.83 | $90.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.67 / $153.08 / $232.40
| Professional | | $81.67 | $153.08 | $232.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.36 / $169.97 / $239.93
| Professional | | $144.36 | $169.97 | $239.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.00 / $138.47 / $303.33
| Professional | | $75.00 | $138.47 | $303.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.50 / $161.13 / $471.06
| Professional | | $107.50 | $161.13 | $471.06 |