- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $48.90 / $238.74 / $457.38
| Facility | 26 | $48.90 | $238.74 | $457.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $189.69 / $205.90 / $205.90
| Professional | | $189.69 | $205.90 | $205.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $252.57 / $335.92 / $1,207.44
| Professional | | $252.57 | $335.92 | $1,207.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $189.20 / $560.66 / $1,059.58
| Professional | | $189.20 | $560.66 | $1,059.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $224.67 / $501.95 / $501.95
| Professional | | $224.67 | $501.95 | $501.95 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $55.11 / $120.54 / $120.54
| Professional | 26 | $55.11 | $120.54 | $120.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $221.66 / $264.26 / $750.87
| Professional | | $221.66 | $264.26 | $750.87 |