- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $72.44 / $213.80 / $302.00
| Facility | 26 | $72.44 | $213.80 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $144.54 / $295.12
| Professional | | $120.23 | $144.54 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $169.82 / $275.42
| Professional | | $138.04 | $169.82 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.88 / $177.83 / $251.19
| Professional | | $154.88 | $177.83 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.90 / $194.98 / $281.84
| Professional | | $134.90 | $194.98 | $281.84 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $173.78 / $338.84 / $338.84
| Facility | 26 | $173.78 | $338.84 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.82 / $177.83 / $912.01
| Professional | | $128.82 | $177.83 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $169.82 / $281.84
| Professional | | $138.04 | $169.82 | $281.84 |