- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $48.87 / $53.75 / $53.75
| Facility | 26 | $48.87 | $53.75 | $53.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.26 / $133.62 / $238.26
| Professional | | $105.26 | $133.62 | $238.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.51 / $107.25 / $242.78
| Professional | | $55.51 | $107.25 | $242.78 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $57.04 / $57.04 / $57.04
| Facility | 26 | $57.04 | $57.04 | $57.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.35 / $153.13 / $331.89
| Professional | | $96.35 | $153.13 | $331.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $185.56 / $202.81 / $223.10
| Professional | | $185.56 | $202.81 | $223.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.03 / $111.95 / $228.34
| Professional | | $85.03 | $111.95 | $228.34 |