- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $50.42 / $50.42 / $50.42
| Facility | 26 | $50.42 | $50.42 | $50.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.20 / $157.08 / $642.25
| Professional | | $97.20 | $157.08 | $642.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.04 / $170.92 / $242.48
| Professional | | $120.04 | $170.92 | $242.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.57 / $67.28 / $99.85
| Professional | | $32.57 | $67.28 | $99.85 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $1,301.63 / $1,301.63 / $1,301.63
| Facility | 26 | $1,301.63 | $1,301.63 | $1,301.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.56 / $188.87 / $255.31
| Professional | | $166.56 | $188.87 | $255.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.65 / $145.41 / $226.08
| Professional | | $107.65 | $145.41 | $226.08 |