- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $48.98 / $48.98 / $48.98
| Facility | 26 | $48.98 | $48.98 | $48.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $177.83 / $263.03
| Professional | | $120.23 | $177.83 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $173.78 / $204.17
| Professional | | $120.23 | $173.78 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $245.47 / $588.84
| Professional | | $181.97 | $245.47 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.72 / $165.96 / $229.09
| Professional | | $97.72 | $165.96 | $229.09 |