- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $48.27 / $48.27 / $81.63
| Facility | 26 | $48.27 | $48.27 | $81.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.47 / $113.68 / $204.88
| Professional | | $101.47 | $113.68 | $204.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.47 / $436.70 / $620.11
| Professional | | $162.47 | $436.70 | $620.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.32 / $75.33 / $146.56
| Professional | | $51.32 | $75.33 | $146.56 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $60.76 / $60.76 / $60.76
| Facility | 26 | $60.76 | $60.76 | $60.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.17 / $277.83 / $858.61
| Professional | | $112.17 | $277.83 | $858.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.09 / $177.46 / $527.63
| Professional | | $118.09 | $177.46 | $527.63 |