- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $57.49 / $57.49 / $103.55
| Facility | 26 | $57.49 | $57.49 | $103.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.87 / $144.60 / $285.79
| Professional | | $119.87 | $144.60 | $285.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $356.38 / $428.38 / $459.68
| Professional | | $356.38 | $428.38 | $459.68 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $70.28 / $70.28 / $70.28
| Facility | 26 | $70.28 | $70.28 | $70.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.24 / $272.02 / $415.78
| Professional | | $129.24 | $272.02 | $415.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.80 / $262.44 / $936.67
| Professional | | $145.80 | $262.44 | $936.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.80 / $254.19 / $358.80
| Professional | | $145.80 | $254.19 | $358.80 |