- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $21.83 / $28.48 / $53.89
| Facility | 26 | $21.83 | $28.48 | $53.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.72 / $150.83 / $166.25
| Professional | | $129.72 | $150.83 | $166.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.28 / $163.28 / $163.28
| Professional | | $163.28 | $163.28 | $163.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.29 / $103.42 / $239.97
| Professional | | $55.29 | $103.42 | $239.97 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $56.90 / $56.90 / $109.00
| Facility | 26 | $56.90 | $56.90 | $109.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $68.11 / $145.30 / $899.44
| Professional | | $68.11 | $145.30 | $899.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $68.11 / $131.27 / $246.11
| Professional | | $68.11 | $131.27 | $246.11 |