- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $99.39 / $99.39 / $185.93
| Facility | 26 | $99.39 | $99.39 | $185.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.19 / $169.35 / $232.34
| Professional | | $153.19 | $169.35 | $232.34 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $67.59 / $71.78 / $85.11
| Professional | 26 | $67.59 | $71.78 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.08 / $181.35 / $314.94
| Professional | | $129.08 | $181.35 | $314.94 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $54.59 / $80.65 / $134.74
| Professional | 26 | $54.59 | $80.65 | $134.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.31 / $183.21 / $393.51
| Professional | | $136.31 | $183.21 | $393.51 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $61.81 / $87.67 / $175.14
| Professional | 26 | $61.81 | $87.67 | $175.14 |