- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $31.23 / $31.23 / $31.23
| Facility | 26 | $31.23 | $31.23 | $31.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.86 / $117.18 / $743.69
| Professional | | $112.86 | $117.18 | $743.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.26 / $137.53 / $263.08
| Professional | | $98.26 | $137.53 | $263.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $92.34 / $131.97
| Professional | | $32.34 | $92.34 | $131.97 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $669.98 / $669.98 / $669.98
| Facility | 26 | $669.98 | $669.98 | $669.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $187.27 / $199.93 / $225.42
| Professional | | $187.27 | $199.93 | $225.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.65 / $130.28 / $214.96
| Professional | | $104.65 | $130.28 | $214.96 |