- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $48.98 / $87.10 / $169.82
| Facility | 26 | $48.98 | $87.10 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $169.82 / $309.03
| Professional | | $120.23 | $169.82 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $208.93 / $338.84
| Professional | | $138.04 | $208.93 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $275.42 / $467.74
| Professional | | $169.82 | $275.42 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $302.00 / $436.52
| Professional | | $190.55 | $302.00 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $38.90 / $61.66 / $112.20
| Professional | 26 | $38.90 | $61.66 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.88 / $213.80 / $426.58
| Professional | | $154.88 | $213.80 | $426.58 |