- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $80.73 / $106.24 / $175.88
| Facility | 26 | $80.73 | $106.24 | $175.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.06 / $137.41 / $224.39
| Professional | | $119.06 | $137.41 | $224.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.96 / $181.18 / $277.69
| Professional | | $130.96 | $181.18 | $277.69 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $99.81 / $99.81 / $99.81
| Facility | 26 | $99.81 | $99.81 | $99.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.60 / $199.41 / $340.27
| Professional | | $139.60 | $199.41 | $340.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.11 / $171.15 / $295.61
| Professional | | $123.11 | $171.15 | $295.61 |