- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $20.29 / $93.67 / $180.79
| Facility | 26 | $20.29 | $93.67 | $180.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.22 / $179.60 / $179.60
| Professional | | $164.22 | $179.60 | $179.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $214.72 / $234.04 / $587.88
| Professional | | $214.72 | $234.04 | $587.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.51 / $232.74 / $918.07
| Professional | | $164.51 | $232.74 | $918.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $195.36 / $435.81 / $435.81
| Professional | | $195.36 | $435.81 | $435.81 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $22.86 / $49.54 / $49.54
| Professional | 26 | $22.86 | $49.54 | $49.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.50 / $220.21 / $651.92
| Professional | | $151.50 | $220.21 | $651.92 |