- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $23.62 / $23.62 / $38.75
| Facility | 26 | $23.62 | $23.62 | $38.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.06 / $86.33 / $108.66
| Professional | | $69.06 | $86.33 | $108.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.78 / $197.18 / $206.79
| Professional | | $159.78 | $197.18 | $206.79 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $25.82 / $25.82 / $25.82
| Facility | 26 | $25.82 | $25.82 | $25.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $59.53 / $129.68 / $213.04
| Professional | | $59.53 | $129.68 | $213.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.75 / $184.68 / $758.00
| Professional | | $92.75 | $184.68 | $758.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.75 / $169.73 / $231.40
| Professional | | $92.75 | $169.73 | $231.40 |