- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $44.85 / $59.02 / $103.40
| Facility | 26 | $44.85 | $59.02 | $103.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.34 / $206.48 / $276.88
| Professional | | $157.34 | $206.48 | $276.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $293.48 / $293.48 / $352.20
| Professional | | $293.48 | $293.48 | $352.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.34 / $135.84 / $419.63
| Professional | | $67.34 | $135.84 | $419.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $271.68 / $391.22 / $882.00
| Professional | | $271.68 | $391.22 | $882.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $59.02 / $84.99 / $222.80
| Professional | 26 | $59.02 | $84.99 | $222.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.46 / $168.90 / $514.50
| Professional | | $90.46 | $168.90 | $514.50 |