- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $18.60 / $22.37 / $125.94
| Facility | 26 | $18.60 | $22.37 | $125.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.02 / $167.27 / $187.76
| Professional | | $124.02 | $167.27 | $187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.10 / $179.55 / $246.55
| Professional | | $23.10 | $179.55 | $246.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.57 / $171.14 / $234.85
| Professional | | $146.57 | $171.14 | $234.85 |
- 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
- $146.88 / $196.08 / $455.30
| Professional | | $146.88 | $196.08 | $455.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.88 / $179.51 / $302.61
| Professional | | $146.88 | $179.51 | $302.61 |