- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $51.64 / $65.01 / $121.41
| Facility | 26 | $51.64 | $65.01 | $121.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.47 / $124.50 / $243.91
| Professional | | $101.47 | $124.50 | $243.91 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $60.04 / $60.04 / $60.04
| Facility | 26 | $60.04 | $60.04 | $60.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.35 / $173.01 / $457.89
| Professional | | $120.35 | $173.01 | $457.89 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $60.76 / $60.76 / $60.76
| Facility | 26 | $60.76 | $60.76 | $60.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.17 / $231.58 / $567.49
| Professional | | $113.17 | $231.58 | $567.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.83 / $191.17 / $472.89
| Professional | | $125.83 | $191.17 | $472.89 |