- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $53.52 / $53.52 / $114.15
| Facility | 26 | $53.52 | $53.52 | $114.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.71 / $109.62 / $250.61
| Professional | | $90.71 | $109.62 | $250.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.56 / $150.56 / $150.56
| Professional | | $150.56 | $150.56 | $150.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.32 / $177.60 / $356.25
| Professional | | $97.32 | $177.60 | $356.25 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $115.42 / $115.42 / $115.42
| Facility | 26 | $115.42 | $115.42 | $115.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.08 / $148.93 / $803.29
| Professional | | $102.08 | $148.93 | $803.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.73 / $137.90 / $284.70
| Professional | | $94.73 | $137.90 | $284.70 |