- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $33.88 / $58.88 / $154.88
| Facility | 26 | $33.88 | $58.88 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.42 / $309.03 / $707.95
| Professional | | $234.42 | $309.03 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $346.74 / $691.83
| Professional | | $251.19 | $346.74 | $691.83 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $9.55 / $53.70 / $165.96
| Facility | 26 | $9.55 | $53.70 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $436.52 / $851.14
| Professional | | $257.04 | $436.52 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $338.84 / $691.83
| Professional | | $245.47 | $338.84 | $691.83 |