- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $86.60 / $86.60 / $90.92
| Facility | 26 | $86.60 | $86.60 | $90.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.30 / $138.21 / $168.97
| Professional | | $126.30 | $138.21 | $168.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.86 / $190.48 / $249.26
| Professional | | $107.86 | $190.48 | $249.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.86 / $213.14 / $324.77
| Professional | | $131.86 | $213.14 | $324.77 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $54.23 / $54.23 / $86.60
| Facility | 26 | $54.23 | $54.23 | $86.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.58 / $136.10 / $191.05
| Professional | | $108.58 | $136.10 | $191.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.76 / $73.79 / $143.46
| Professional | | $55.76 | $73.79 | $143.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.44 / $164.95 / $237.93
| Professional | | $131.44 | $164.95 | $237.93 |