- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $19.69 / $19.69 / $97.28
| Facility | 26 | $19.69 | $19.69 | $97.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.68 / $170.92 / $244.16
| Professional | | $138.68 | $170.92 | $244.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.82 / $276.64 / $464.60
| Professional | | $168.82 | $276.64 | $464.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.76 / $225.70 / $313.18
| Professional | | $190.76 | $225.70 | $313.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.22 / $221.95 / $329.64
| Professional | | $184.22 | $221.95 | $329.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.84 / $201.03 / $378.62
| Professional | | $137.84 | $201.03 | $378.62 |