- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $47.76 / $55.52 / $66.22
| Facility | 26 | $47.76 | $55.52 | $66.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.95 / $215.86 / $221.03
| Professional | | $125.95 | $215.86 | $221.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $178.34 / $204.56 / $262.26
| Professional | | $178.34 | $204.56 | $262.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.71 / $229.66 / $321.48
| Professional | | $159.71 | $229.66 | $321.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.28 / $189.13 / $310.93
| Professional | | $135.28 | $189.13 | $310.93 |