- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $25.25 / $25.25 / $41.08
| Facility | 26 | $25.25 | $25.25 | $41.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.35 / $136.46 / $166.26
| Professional | | $104.35 | $136.46 | $166.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.01 / $324.57 / $340.38
| Professional | | $263.01 | $324.57 | $340.38 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $27.06 / $27.06 / $27.06
| Facility | 26 | $27.06 | $27.06 | $27.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.94 / $184.44 / $314.85
| Professional | | $75.94 | $184.44 | $314.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.49 / $513.85 / $899.44
| Professional | | $125.49 | $513.85 | $899.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.49 / $296.95 / $877.17
| Professional | | $125.49 | $296.95 | $877.17 |