- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $49.50 / $49.50 / $356.49
| Facility | 26 | $49.50 | $49.50 | $356.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $220.66 / $240.40 / $240.40
| Professional | | $220.66 | $240.40 | $240.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $268.14 / $268.14 / $621.91
| Professional | | $268.14 | $268.14 | $621.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $228.24 / $362.33 / $1,182.98
| Professional | | $228.24 | $362.33 | $1,182.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $271.04 / $595.16 / $595.16
| Professional | | $271.04 | $595.16 | $595.16 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $56.78 / $122.61 / $122.61
| Professional | 26 | $56.78 | $122.61 | $122.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $196.97 / $553.20 / $843.81
| Professional | | $196.97 | $553.20 | $843.81 |