- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $53.88 / $56.74 / $61.84
| Facility | 26 | $53.88 | $56.74 | $61.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.30 / $194.71 / $260.42
| Professional | | $165.30 | $194.71 | $260.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.37 / $212.86 / $351.81
| Professional | | $165.37 | $212.86 | $351.81 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $59.66 / $59.66 / $59.66
| Facility | 26 | $59.66 | $59.66 | $59.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.43 / $262.01 / $473.77
| Professional | | $162.43 | $262.01 | $473.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.86 / $239.07 / $436.71
| Professional | | $157.86 | $239.07 | $436.71 |