- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $59.76 / $59.76 / $106.76
| Facility | 26 | $59.76 | $59.76 | $106.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $230.30 / $324.43 / $358.48
| Professional | | $230.30 | $324.43 | $358.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.54 / $162.72 / $506.55
| Professional | | $83.54 | $162.72 | $506.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $280.97 / $314.02 / $488.11
| Professional | | $280.97 | $314.02 | $488.11 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $172.46 / $336.07 / $336.07
| Facility | 26 | $172.46 | $336.07 | $336.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $311.67 / $403.88 / $762.67
| Professional | | $311.67 | $403.88 | $762.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $293.33 / $393.33 / $507.46
| Professional | | $293.33 | $393.33 | $507.46 |