- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $96.77 / $123.70 / $226.29
| Facility | 26 | $96.77 | $123.70 | $226.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.44 / $229.89 / $315.64
| Professional | | $165.44 | $229.89 | $315.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.04 / $273.12 / $446.90
| Professional | | $198.04 | $273.12 | $446.90 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $113.41 / $113.41 / $113.41
| Facility | 26 | $113.41 | $113.41 | $113.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $197.27 / $299.33 / $536.74
| Professional | | $197.27 | $299.33 | $536.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.32 / $252.63 / $443.66
| Professional | | $198.32 | $252.63 | $443.66 |