- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $31.53 / $71.75 / $158.99
| Facility | 26 | $31.53 | $71.75 | $158.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.02 / $160.12 / $381.68
| Professional | | $137.02 | $160.12 | $381.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.84 / $199.03 / $395.82
| Professional | | $140.84 | $199.03 | $395.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.36 / $273.45 / $467.83
| Professional | | $162.36 | $273.45 | $467.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.04 / $290.20 / $433.03
| Professional | | $182.04 | $290.20 | $433.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $38.18 / $60.87 / $111.43
| Professional | 26 | $38.18 | $60.87 | $111.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.00 / $235.14 / $406.94
| Professional | | $157.00 | $235.14 | $406.94 |