- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $85.76 / $85.76 / $108.45
| Facility | 26 | $85.76 | $85.76 | $108.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.29 / $141.04 / $218.56
| Professional | | $126.29 | $141.04 | $218.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.66 / $192.69 / $311.33
| Professional | | $149.66 | $192.69 | $311.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.56 / $188.68 / $312.86
| Professional | | $127.56 | $188.68 | $312.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.05 / $212.24 / $265.97
| Professional | | $141.05 | $212.24 | $265.97 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $85.76 / $129.05 / $161.72
| Professional | 26 | $85.76 | $129.05 | $161.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.59 / $227.36 / $353.68
| Professional | | $130.59 | $227.36 | $353.68 |