- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $19.69 / $19.69 / $98.80
| Facility | 26 | $19.69 | $19.69 | $98.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.36 / $179.60 / $223.07
| Professional | | $132.36 | $179.60 | $223.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.57 / $224.23 / $382.56
| Professional | | $141.57 | $224.23 | $382.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $252.94 / $252.94 / $252.94
| Professional | | $252.94 | $252.94 | $252.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.20 / $196.71 / $256.86
| Professional | | $167.20 | $196.71 | $256.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.62 / $224.89 / $393.35
| Professional | | $141.62 | $224.89 | $393.35 |