- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $62.53 / $73.00 / $102.29
| Facility | 26 | $62.53 | $73.00 | $102.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.87 / $159.28 / $294.73
| Professional | | $119.87 | $159.28 | $294.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.47 / $206.50 / $249.73
| Professional | | $151.47 | $206.50 | $249.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.69 / $159.52 / $249.07
| Professional | | $103.69 | $159.52 | $249.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.05 / $143.85 / $218.70
| Professional | | $95.05 | $143.85 | $218.70 |