- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $57.71 / $57.71 / $57.71
| Facility | 26 | $57.71 | $57.71 | $57.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $189.51 / $250.54 / $250.54
| Professional | | $189.51 | $250.54 | $250.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $220.13 / $245.89 / $779.50
| Professional | | $220.13 | $245.89 | $779.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.38 / $293.75 / $592.37
| Professional | | $199.38 | $293.75 | $592.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $255.96 / $447.46 / $447.46
| Professional | | $255.96 | $447.46 | $447.46 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $47.55 / $103.89 / $103.89
| Professional | 26 | $47.55 | $103.89 | $103.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.52 / $360.03 / $622.91
| Professional | | $166.52 | $360.03 | $622.91 |