- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $32.79 / $113.46 / $316.57
| Facility | 26 | $32.79 | $113.46 | $316.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $256.89 / $280.95 / $280.95
| Professional | | $256.89 | $280.95 | $280.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $358.35 / $390.60 / $1,100.21
| Professional | | $358.35 | $390.60 | $1,100.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.63 / $435.70 / $1,448.03
| Professional | | $251.63 | $435.70 | $1,448.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $298.81 / $673.29 / $673.29
| Professional | | $298.81 | $673.29 | $673.29 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $36.95 / $80.54 / $80.54
| Professional | 26 | $36.95 | $80.54 | $80.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $259.85 / $351.51 / $1,007.17
| Professional | | $259.85 | $351.51 | $1,007.17 |