- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $19.86 / $46.08 / $101.06
| Facility | 26 | $19.86 | $46.08 | $101.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.88 / $168.35 / $410.28
| Professional | | $142.88 | $168.35 | $410.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.60 / $215.54 / $424.95
| Professional | | $152.60 | $215.54 | $424.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.57 / $282.85 / $490.09
| Professional | | $169.57 | $282.85 | $490.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $191.54 / $305.35 / $455.61
| Professional | | $191.54 | $305.35 | $455.61 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $24.27 / $38.68 / $68.30
| Professional | 26 | $24.27 | $38.68 | $68.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.03 / $241.64 / $406.91
| Professional | | $161.03 | $241.64 | $406.91 |