- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $93.99 / $120.19 / $209.85
| Facility | 26 | $93.99 | $120.19 | $209.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $233.65 / $288.72 / $535.37
| Professional | | $233.65 | $288.72 | $535.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $254.31 / $343.01 / $572.07
| Professional | | $254.31 | $343.01 | $572.07 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $130.09 / $130.09 / $130.09
| Facility | 26 | $130.09 | $130.09 | $130.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $259.20 / $370.71 / $694.71
| Professional | | $259.20 | $370.71 | $694.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.77 / $344.84 / $570.04
| Professional | | $245.77 | $344.84 | $570.04 |