- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $48.45 / $49.93 / $128.51
| Facility | 26 | $48.45 | $49.93 | $128.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.81 / $112.66 / $223.09
| Professional | | $96.81 | $112.66 | $223.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.01 / $145.06 / $227.92
| Professional | | $100.01 | $145.06 | $227.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.52 / $140.88 / $273.24
| Professional | | $98.52 | $140.88 | $273.24 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $115.42 / $247.81 / $247.81
| Facility | 26 | $115.42 | $247.81 | $247.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $803.29 / $803.29 / $918.75
| Professional | | $803.29 | $803.29 | $918.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.53 / $137.78 / $249.15
| Professional | | $95.53 | $137.78 | $249.15 |