- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $20.71 / $20.71 / $34.65
| Facility | 26 | $20.71 | $20.71 | $34.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.30 / $206.24 / $259.27
| Professional | | $152.30 | $206.24 | $259.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.71 / $333.91 / $500.86
| Professional | | $140.71 | $333.91 | $500.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.78 / $205.01 / $267.99
| Professional | | $21.78 | $205.01 | $267.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.53 / $195.29 / $440.76
| Professional | | $102.53 | $195.29 | $440.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.15 / $202.69 / $331.82
| Professional | | $137.15 | $202.69 | $331.82 |