- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $56.20 / $76.68 / $125.88
| Facility | 26 | $56.20 | $76.68 | $125.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.46 / $134.19 / $217.78
| Professional | | $112.46 | $134.19 | $217.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.99 / $147.03 / $244.43
| Professional | | $111.99 | $147.03 | $244.43 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $109.39 / $126.04 / $145.54
| Facility | 26 | $109.39 | $126.04 | $145.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.64 / $176.64 / $295.89
| Professional | | $108.64 | $176.64 | $295.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.57 / $147.32 / $261.01
| Professional | | $117.57 | $147.32 | $261.01 |