- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $108.04 / $112.58 / $126.07
| Facility | 26 | $108.04 | $112.58 | $126.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $179.85 / $231.96 / $347.69
| Professional | | $179.85 | $231.96 | $347.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $171.63 / $238.90 / $412.48
| Professional | | $171.63 | $238.90 | $412.48 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $118.15 / $118.15 / $118.15
| Facility | 26 | $118.15 | $118.15 | $118.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.15 / $296.48 / $542.50
| Professional | | $180.15 | $296.48 | $542.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $189.75 / $286.75 / $531.03
| Professional | | $189.75 | $286.75 | $531.03 |