- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $46.88 / $46.88 / $46.88
| Facility | 26 | $46.88 | $46.88 | $46.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $178.45 / $250.54 / $265.74
| Professional | | $178.45 | $250.54 | $265.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.07 / $52.07 / $52.07
| Professional | | $52.07 | $52.07 | $52.07 |
- 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
- $143.30 / $290.33 / $1,103.83
| Professional | | $143.30 | $290.33 | $1,103.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.86 / $299.33 / $462.34
| Professional | | $162.86 | $299.33 | $462.34 |