- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $94.25 / $103.40 / $134.19
| Facility | 26 | $94.25 | $103.40 | $134.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $253.88 / $435.22 / $613.51
| Professional | | $253.88 | $435.22 | $613.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.23 / $397.10 / $707.87
| Professional | | $223.23 | $397.10 | $707.87 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $104.54 / $104.54 / $104.54
| Facility | 26 | $104.54 | $104.54 | $104.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $274.74 / $458.52 / $921.91
| Professional | | $274.74 | $458.52 | $921.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.27 / $415.87 / $847.02
| Professional | | $257.27 | $415.87 | $847.02 |