- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $34.85 / $277.91 / $655.12
| Facility | 26 | $34.85 | $277.91 | $655.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.81 / $64.81 / $161.71
| Professional | | $64.81 | $64.81 | $161.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.05 / $97.65 / $476.43
| Professional | | $90.05 | $97.65 | $476.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.16 / $188.70 / $338.68
| Professional | | $60.16 | $188.70 | $338.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.20 / $159.72 / $159.72
| Professional | | $75.20 | $159.72 | $159.72 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $41.28 / $86.35 / $86.35
| Professional | 26 | $41.28 | $86.35 | $86.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.80 / $130.19 / $231.44
| Professional | | $86.80 | $130.19 | $231.44 |