- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $72.44 / $125.89 / $331.13
| Facility | 26 | $72.44 | $125.89 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $138.04 / $338.84
| Professional | | $104.71 | $138.04 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.90 / $186.21 / $346.74
| Professional | | $134.90 | $186.21 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $20.42 / $114.82 / $338.84
| Facility | 26 | $20.42 | $114.82 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.49 / $213.80 / $398.11
| Professional | | $117.49 | $213.80 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.49 / $162.18 / $309.03
| Professional | | $117.49 | $162.18 | $309.03 |