- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $102.14 / $127.06 / $166.49
| Facility | 26 | $102.14 | $127.06 | $166.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.55 / $266.76 / $299.58
| Professional | | $168.55 | $266.76 | $299.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $247.83 / $313.77 / $394.73
| Professional | | $247.83 | $313.77 | $394.73 |
- 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
- $153.04 / $242.97 / $419.66
| Professional | | $153.04 | $242.97 | $419.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.37 / $240.00 / $336.39
| Professional | | $172.37 | $240.00 | $336.39 |