- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $20.05 / $38.72 / $52.29
| Facility | 26 | $20.05 | $38.72 | $52.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $156.85 / $173.49 / $307.17
| Professional | | $156.85 | $173.49 | $307.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.26 / $214.10 / $316.64
| Professional | | $163.26 | $214.10 | $316.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.90 / $246.26 / $404.97
| Professional | | $132.90 | $246.26 | $404.97 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $54.18 / $122.00 / $122.00
| Facility | 26 | $54.18 | $122.00 | $122.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.19 / $237.58 / $1,203.75
| Professional | | $169.19 | $237.58 | $1,203.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.00 / $237.58 / $397.77
| Professional | | $170.00 | $237.58 | $397.77 |