- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $44.71 / $44.71 / $44.71
| Facility | 26 | $44.71 | $44.71 | $44.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.34 / $192.51 / $276.88
| Professional | | $157.34 | $192.51 | $276.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.28 / $294.89 / $362.85
| Professional | | $75.28 | $294.89 | $362.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.89 / $117.98 / $407.17
| Professional | | $63.89 | $117.98 | $407.17 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $142.34 / $270.97 / $270.97
| Facility | 26 | $142.34 | $270.97 | $270.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.05 / $168.90 / $558.37
| Professional | | $95.05 | $168.90 | $558.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.05 / $168.90 / $337.80
| Professional | | $95.05 | $168.90 | $337.80 |