- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $22.97 / $22.97 / $65.48
| Facility | 26 | $22.97 | $22.97 | $65.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.71 / $110.46 / $140.00
| Professional | | $86.71 | $110.46 | $140.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.00 / $120.79 / $172.68
| Professional | | $108.00 | $120.79 | $172.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.04 / $129.16 / $236.35
| Professional | | $90.04 | $129.16 | $236.35 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $39.45 / $47.00 / $82.51
| Facility | 26 | $39.45 | $47.00 | $82.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $492.35 / $492.35 / $492.35
| Professional | | $492.35 | $492.35 | $492.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.14 / $118.03 / $177.87
| Professional | | $44.14 | $118.03 | $177.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.88 / $128.47 / $244.11
| Professional | | $88.88 | $128.47 | $244.11 |