- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $57.54 / $75.86 / $154.88
| Facility | 26 | $57.54 | $75.86 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $141.25 / $204.17
| Professional | | $107.15 | $141.25 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.33 / $138.04 / $269.15
| Professional | | $93.33 | $138.04 | $269.15 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $14.79 / $79.43 / $218.78
| Facility | 26 | $14.79 | $79.43 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $181.97 / $407.38
| Professional | | $104.71 | $181.97 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $147.91 / $295.12
| Professional | | $100.00 | $147.91 | $295.12 |