- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $57.48 / $57.48 / $57.48
| Facility | 26 | $57.48 | $57.48 | $57.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.20 / $133.62 / $597.50
| Professional | | $110.20 | $133.62 | $597.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.60 / $159.52 / $236.23
| Professional | | $120.60 | $159.52 | $236.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $65.98 / $98.98
| Professional | | $32.34 | $65.98 | $98.98 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $198.33 / $198.33 / $198.33
| Facility | 26 | $198.33 | $198.33 | $198.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.47 / $212.38 / $250.84
| Professional | | $176.47 | $212.38 | $250.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.15 / $122.99 / $198.30
| Professional | | $115.15 | $122.99 | $198.30 |