- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $51.98 / $51.98 / $51.98
| Facility | 26 | $51.98 | $51.98 | $51.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.92 / $131.60 / $228.05
| Professional | | $105.92 | $131.60 | $228.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.42 / $61.42 / $61.42
| Professional | | $61.42 | $61.42 | $61.42 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $60.80 / $60.80 / $60.80
| Facility | 26 | $60.80 | $60.80 | $60.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.05 / $266.87 / $2,247.52
| Professional | | $92.05 | $266.87 | $2,247.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.76 / $281.23 / $717.40
| Professional | | $105.76 | $281.23 | $717.40 |