- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $30.20 / $52.48 / $147.91
| Facility | 26 | $30.20 | $52.48 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $223.87 / $501.19
| Professional | | $177.83 | $223.87 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $251.19 / $501.19
| Professional | | $173.78 | $251.19 | $501.19 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $8.51 / $47.86 / $147.91
| Facility | 26 | $8.51 | $47.86 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $331.13 / $645.65
| Professional | | $186.21 | $331.13 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $251.19 / $512.86
| Professional | | $169.82 | $251.19 | $512.86 |