- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $96.24 / $110.81 / $166.39
| Facility | 26 | $96.24 | $110.81 | $166.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.61 / $177.00 / $278.97
| Professional | | $148.61 | $177.00 | $278.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.33 / $194.71 / $334.74
| Professional | | $143.33 | $194.71 | $334.74 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $102.91 / $102.91 / $102.91
| Facility | 26 | $102.91 | $102.91 | $102.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.31 / $222.16 / $399.66
| Professional | | $164.31 | $222.16 | $399.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.88 / $197.37 / $330.84
| Professional | | $146.88 | $197.37 | $330.84 |