- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $87.10 / $102.33 / $186.21
| Facility | 26 | $87.10 | $102.33 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $165.96 / $257.04
| Professional | | $144.54 | $165.96 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $63.10 / $70.79 / $190.55
| Professional | 26 | $63.10 | $70.79 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $181.97 / $316.23
| Professional | | $125.89 | $181.97 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $53.70 / $85.11 / $134.90
| Professional | 26 | $53.70 | $85.11 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $186.21 / $316.23
| Professional | | $141.25 | $186.21 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $60.26 / $85.11 / $134.90
| Professional | 26 | $60.26 | $85.11 | $134.90 |