- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $89.13 / $89.13 / $89.13
| Facility | 26 | $89.13 | $89.13 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $208.93 / $426.58
| Professional | | $141.25 | $208.93 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $53.70 / $102.33 / $208.93
| Professional | 26 | $53.70 | $102.33 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $676.08 / $676.08
| Professional | | $436.52 | $676.08 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $239.88 / $371.54 / $371.54
| Professional | 26 | $239.88 | $371.54 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $295.12 / $489.78
| Professional | | $199.53 | $295.12 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $63.10 / $114.82 / $194.98
| Professional | 26 | $63.10 | $114.82 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.42 / $331.13 / $724.44
| Professional | | $234.42 | $331.13 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $56.23 / $165.96 / $208.93
| Professional | 26 | $56.23 | $165.96 | $208.93 |