- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $92.20 / $92.21 / $92.21
| Facility | 26 | $92.20 | $92.21 | $92.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.49 / $153.74 / $202.42
| Professional | | $134.49 | $153.74 | $202.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.84 / $202.50 / $298.70
| Professional | | $135.84 | $202.50 | $298.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.67 / $220.89 / $295.62
| Professional | | $165.67 | $220.89 | $295.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.31 / $217.38 / $330.66
| Professional | | $154.31 | $217.38 | $330.66 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $87.22 / $121.28 / $186.91
| Professional | 26 | $87.22 | $121.28 | $186.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.39 / $227.54 / $520.78
| Professional | | $170.39 | $227.54 | $520.78 |