- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $16.98 / $83.18 / $125.89
| Facility | 26 | $16.98 | $83.18 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $154.88 / $630.96
| Professional | | $125.89 | $154.88 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.44 / $323.59 / $676.08
| Professional | | $23.44 | $323.59 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $190.55 / $891.25
| Professional | | $162.18 | $190.55 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $218.78 / $426.58
| Professional | | $190.55 | $218.78 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $20.42 / $23.44 / $43.65
| Professional | 26 | $20.42 | $23.44 | $43.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $239.88 / $630.96
| Professional | | $141.25 | $239.88 | $630.96 |