- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $61.85 / $65.57 / $103.74
| Facility | 26 | $61.85 | $65.57 | $103.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.18 / $173.29 / $297.41
| Professional | | $152.18 | $173.29 | $297.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.72 / $296.36 / $491.19
| Professional | | $154.72 | $296.36 | $491.19 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $67.42 / $67.42 / $67.42
| Facility | 26 | $67.42 | $67.42 | $67.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $297.89 / $445.56 / $802.22
| Professional | | $297.89 | $445.56 | $802.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $283.86 / $412.70 / $719.97
| Professional | | $283.86 | $412.70 | $719.97 |