- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $66.11 / $66.11 / $476.11
| Facility | 26 | $66.11 | $66.11 | $476.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.65 / $139.18 / $139.18
| Professional | | $129.65 | $139.18 | $139.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.22 / $166.22 / $544.92
| Professional | | $166.22 | $166.22 | $544.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.87 / $226.57 / $675.60
| Professional | | $133.87 | $226.57 | $675.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.97 / $345.99 / $345.99
| Professional | | $158.97 | $345.99 | $345.99 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $75.47 / $163.75 / $163.75
| Professional | 26 | $75.47 | $163.75 | $163.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.78 / $177.66 / $490.52
| Professional | | $118.78 | $177.66 | $490.52 |