- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $38.84 / $38.84 / $38.84
| Facility | 26 | $38.84 | $38.84 | $38.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.87 / $167.09 / $226.85
| Professional | | $152.87 | $167.09 | $226.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.71 / $252.79 / $410.41
| Professional | | $164.71 | $252.79 | $410.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.60 / $180.15 / $254.45
| Professional | | $44.60 | $180.15 | $254.45 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $52.38 / $52.38 / $52.38
| Facility | 26 | $52.38 | $52.38 | $52.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.85 / $271.91 / $503.57
| Professional | | $170.85 | $271.91 | $503.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $179.21 / $238.46 / $348.56
| Professional | | $179.21 | $238.46 | $348.56 |