- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $78.01 / $78.01 / $99.60
| Facility | 26 | $78.01 | $78.01 | $99.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.35 / $127.30 / $140.08
| Professional | | $120.35 | $127.30 | $140.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.97 / $193.48 / $274.74
| Professional | | $142.97 | $193.48 | $274.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.83 / $97.26 / $167.08
| Professional | | $52.83 | $97.26 | $167.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.41 / $221.09 / $311.76
| Professional | | $151.41 | $221.09 | $311.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.32 / $156.63 / $254.65
| Professional | | $127.32 | $156.63 | $254.65 |