- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $79.55 / $79.55 / $79.55
| Facility | 26 | $79.55 | $79.55 | $79.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.72 / $155.34 / $864.73
| Professional | | $144.72 | $155.34 | $864.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.54 / $193.39 / $272.60
| Professional | | $173.54 | $193.39 | $272.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.30 / $64.69 / $133.49
| Professional | | $47.30 | $64.69 | $133.49 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $616.40 / $616.40 / $616.40
| Facility | 26 | $616.40 | $616.40 | $616.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $220.60 / $267.22 / $295.74
| Professional | | $220.60 | $267.22 | $295.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.66 / $190.83 / $251.89
| Professional | | $152.66 | $190.83 | $251.89 |