- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $53.03 / $53.03 / $68.58
| Facility | 26 | $53.03 | $53.03 | $68.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $220.11 / $224.61 / $257.14
| Professional | | $220.11 | $224.61 | $257.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $202.67 / $208.75 / $310.32
| Professional | | $202.67 | $208.75 | $310.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $59.34 / $85.14 / $332.00
| Professional | | $59.34 | $85.14 | $332.00 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $62.66 / $62.66 / $62.66
| Facility | 26 | $62.66 | $62.66 | $62.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.06 / $305.35 / $458.25
| Professional | | $229.06 | $305.35 | $458.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $239.36
| Professional | | $32.34 | $32.34 | $239.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $202.88 / $232.14 / $327.68
| Professional | | $202.88 | $232.14 | $327.68 |