- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $32.03 / $32.03 / $54.00
| Facility | 26 | $32.03 | $32.03 | $54.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $99.62 / $113.59 / $206.70
| Professional | | $99.62 | $113.59 | $206.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $82.14 / $98.29 / $154.88
| Professional | | $82.14 | $98.29 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.00 / $107.30 / $161.58
| Professional | | $89.00 | $107.30 | $161.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.95 / $81.98 / $129.91
| Professional | | $33.95 | $81.98 | $129.91 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $39.29 / $39.29 / $39.29
| Facility | 26 | $39.29 | $39.29 | $39.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.01 / $132.80 / $237.56
| Professional | | $103.01 | $132.80 | $237.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.01 / $121.26 / $198.40
| Professional | | $97.01 | $121.26 | $198.40 |