- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $35.63 / $42.69 / $244.71
| Facility | 26 | $35.63 | $42.69 | $244.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.05 / $198.76 / $221.98
| Professional | | $147.05 | $198.76 | $221.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.81 / $213.50 / $293.17
| Professional | | $46.81 | $213.50 | $293.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.77 / $206.00 / $324.77
| Professional | | $181.77 | $206.00 | $324.77 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $104.72 / $201.06 / $201.06
| Facility | 26 | $104.72 | $201.06 | $201.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.50 / $240.36 / $539.42
| Professional | | $199.50 | $240.36 | $539.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.29 / $216.31 / $471.82
| Professional | | $192.29 | $216.31 | $471.82 |