- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $18.62 / $34.67 / $69.18
| Facility | 26 | $18.62 | $34.67 | $69.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $91.20 / $251.19
| Professional | | $60.26 | $91.20 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.20 / $141.25 / $186.21
| Professional | | $91.20 | $141.25 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $144.54 / $288.40
| Professional | | $109.65 | $144.54 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $165.96 / $245.47
| Professional | | $104.71 | $165.96 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $123.03 / $223.87
| Professional | | $79.43 | $123.03 | $223.87 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $11.48 / $13.49 / $13.49
| Facility | 26 | $11.48 | $13.49 | $13.49 |