- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $33.40 / $33.40 / $56.55
| Facility | 26 | $33.40 | $33.40 | $56.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.85 / $157.01 / $167.37
| Professional | | $150.85 | $157.01 | $167.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.65 / $132.65 / $186.70
| Professional | | $132.65 | $132.65 | $186.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.51 / $150.28 / $199.77
| Professional | | $38.51 | $150.28 | $199.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.78 / $198.06 / $369.56
| Professional | | $140.78 | $198.06 | $369.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.69 / $195.64 / $344.29
| Professional | | $150.69 | $195.64 | $344.29 |