- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $18.20 / $46.77 / $95.50
| Facility | 26 | $18.20 | $46.77 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $181.97 / $309.03
| Professional | | $125.89 | $181.97 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $208.93 / $338.84
| Professional | | $125.89 | $208.93 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $263.03 / $478.63
| Professional | | $162.18 | $263.03 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $269.15 / $446.68
| Professional | | $190.55 | $269.15 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $21.88 / $34.67 / $61.66
| Professional | 26 | $21.88 | $34.67 | $61.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.90 / $213.80 / $426.58
| Professional | | $134.90 | $213.80 | $426.58 |