- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $31.66 / $31.66 / $38.32
| Facility | 26 | $31.66 | $31.66 | $38.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.02 / $157.71 / $238.69
| Professional | | $124.02 | $157.71 | $238.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.72 / $178.50 / $214.39
| Professional | | $151.72 | $178.50 | $214.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.94 / $157.07 / $249.28
| Professional | | $103.94 | $157.07 | $249.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.99 / $135.72 / $234.23
| Professional | | $94.99 | $135.72 | $234.23 |