- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $52.48 / $89.13 / $223.87
| Facility | 26 | $52.48 | $89.13 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $158.49 / $524.81
| Professional | | $109.65 | $158.49 | $524.81 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $66.07 / $66.07 / $66.07
| Facility | 26 | $66.07 | $66.07 | $66.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $165.96 / $302.00
| Professional | | $114.82 | $165.96 | $302.00 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $15.14 / $81.28 / $181.97
| Facility | 26 | $15.14 | $81.28 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $181.97 / $407.38
| Professional | | $114.82 | $181.97 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $144.54 / $288.40
| Professional | | $107.15 | $144.54 | $288.40 |