- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $54.06 / $54.06 / $94.56
| Facility | 26 | $54.06 | $54.06 | $94.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.87 / $143.88 / $197.03
| Professional | | $119.87 | $143.88 | $197.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.65 / $126.20 / $189.30
| Professional | | $108.65 | $126.20 | $189.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $59.45 / $115.97 / $201.73
| Professional | | $59.45 | $115.97 | $201.73 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $70.28 / $70.28 / $70.28
| Facility | 26 | $70.28 | $70.28 | $70.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.70 / $169.51 / $290.49
| Professional | | $120.70 | $169.51 | $290.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.09 / $140.57 / $233.28
| Professional | | $114.09 | $140.57 | $233.28 |