- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $72.44 / $173.78 / $398.11
| Facility | 26 | $72.44 | $173.78 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.20 / $134.90 / $302.00
| Professional | | $91.20 | $134.90 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $181.97 / $316.23
| Professional | | $131.83 | $181.97 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.82 / $229.09 / $398.11
| Professional | | $128.82 | $229.09 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $173.78 / $501.19
| Professional | | $147.91 | $173.78 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $91.20 / $107.15 / $181.97
| Professional | 26 | $91.20 | $107.15 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $177.83 / $331.13
| Professional | | $125.89 | $177.83 | $331.13 |