- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $47.43 / $47.43 / $47.43
| Facility | 26 | $47.43 | $47.43 | $47.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.88 / $204.23 / $305.35
| Professional | | $152.88 | $204.23 | $305.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $451.85 / $535.89 / $600.47
| Professional | | $451.85 | $535.89 | $600.47 |
- 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
- $232.43 / $380.72 / $640.96
| Professional | | $232.43 | $380.72 | $640.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $225.89 / $420.36 / $1,494.48
| Professional | | $225.89 | $420.36 | $1,494.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $205.35 / $378.32 / $495.03
| Professional | | $205.35 | $378.32 | $495.03 |