- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $79.43 / $109.65 / $213.80
| Facility | 26 | $79.43 | $109.65 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.82 / $154.88 / $269.15
| Professional | | $128.82 | $154.88 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $165.96 / $295.12
| Professional | | $112.20 | $165.96 | $295.12 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $20.89 / $109.65 / $302.00
| Facility | 26 | $20.89 | $109.65 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $218.78 / $457.09
| Professional | | $147.91 | $218.78 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.82 / $181.97 / $331.13
| Professional | | $128.82 | $181.97 | $331.13 |