- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $56.23 / $56.23 / $89.13
| Facility | 26 | $56.23 | $56.23 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.18 / $97.72 / $186.21
| Professional | | $83.18 | $97.72 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.11 / $93.33 / $107.15
| Professional | | $85.11 | $93.33 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $141.25 / $204.17
| Professional | | $100.00 | $141.25 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.72 / $138.04 / $316.23
| Professional | | $97.72 | $138.04 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $54.95 / $77.62 / $173.78
| Professional | 26 | $54.95 | $77.62 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.13 / $97.72 / $112.20
| Professional | | $89.13 | $97.72 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.72 / $138.04 / $208.93
| Professional | | $97.72 | $138.04 | $208.93 |