- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $22.31 / $29.45 / $52.29
| Facility | 26 | $22.31 | $29.45 | $52.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.69 / $188.11 / $307.17
| Professional | | $159.69 | $188.11 | $307.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.26 / $214.10 / $340.98
| Professional | | $163.26 | $214.10 | $340.98 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $25.91 / $25.91 / $25.91
| Facility | 26 | $25.91 | $25.91 | $25.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.47 / $256.12 / $426.41
| Professional | | $161.47 | $256.12 | $426.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.26 / $212.42 / $393.35
| Professional | | $153.26 | $212.42 | $393.35 |