- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $18.62 / $28.18 / $33.11
| Facility | 26 | $18.62 | $28.18 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $169.82 / $302.00
| Professional | | $147.91 | $169.82 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $128.82 / $199.53
| Professional | | $112.20 | $128.82 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $199.53 / $371.54
| Professional | | $125.89 | $199.53 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $194.98 / $323.59
| Professional | | $141.25 | $194.98 | $323.59 |