- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $55.00 / $110.90 / $246.66
| Facility | 26 | $55.00 | $110.90 | $246.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.19 / $275.00 / $366.85
| Professional | | $134.19 | $275.00 | $366.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.34 / $160.66 / $308.35
| Professional | | $107.34 | $160.66 | $308.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.06 / $209.98 / $325.01
| Professional | | $133.06 | $209.98 | $325.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.52 / $123.65 / $435.18
| Professional | | $107.52 | $123.65 | $435.18 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $53.30 / $61.30 / $184.46
| Professional | 26 | $53.30 | $61.30 | $184.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.60 / $170.09 / $265.41
| Professional | | $117.60 | $170.09 | $265.41 |