- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $85.11 / $85.11 / $169.82
| Facility | 26 | $85.11 | $85.11 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $141.25 / $338.84
| Professional | | $104.71 | $141.25 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $190.55 / $269.15
| Professional | | $144.54 | $190.55 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.82 / $190.55 / $316.23
| Professional | | $128.82 | $190.55 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.98 / $213.80 / $741.31
| Professional | | $194.98 | $213.80 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $117.49 / $128.82 / $389.05
| Professional | 26 | $117.49 | $128.82 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $138.04 / $138.04
| Professional | | $125.89 | $138.04 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $208.93 / $338.84
| Professional | | $131.83 | $208.93 | $338.84 |