- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $46.77 / $66.07 / $131.83
| Facility | 26 | $46.77 | $66.07 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.33 / $114.82 / $269.15
| Professional | | $93.33 | $114.82 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.18 / $120.23 / $218.78
| Professional | | $83.18 | $120.23 | $218.78 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $12.02 / $64.57 / $177.83
| Facility | 26 | $12.02 | $64.57 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.33 / $154.88 / $338.84
| Professional | | $93.33 | $154.88 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.10 / $128.82 / $257.04
| Professional | | $87.10 | $128.82 | $257.04 |