- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $30.75 / $98.15 / $274.47
| Facility | 26 | $30.75 | $98.15 | $274.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $196.73 / $214.74 / $519.66
| Professional | | $196.73 | $214.74 | $519.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.64 / $267.75 / $722.52
| Professional | | $245.64 | $267.75 | $722.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.47 / $285.61 / $1,100.68
| Professional | | $194.47 | $285.61 | $1,100.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $230.94 / $517.36 / $517.36
| Professional | | $230.94 | $517.36 | $517.36 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $34.63 / $75.43 / $75.43
| Professional | 26 | $34.63 | $75.43 | $75.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.50 / $266.14 / $773.92
| Professional | | $169.50 | $266.14 | $773.92 |