- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $38.02 / $51.29 / $104.71
| Facility | 26 | $38.02 | $51.29 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $104.71 / $186.21
| Professional | | $79.43 | $104.71 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.61 / $102.33 / $204.17
| Professional | | $67.61 | $102.33 | $204.17 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $10.00 / $53.70 / $144.54
| Facility | 26 | $10.00 | $53.70 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.62 / $138.04 / $316.23
| Professional | | $77.62 | $138.04 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.44 / $109.65 / $229.09
| Professional | | $72.44 | $109.65 | $229.09 |