- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $44.33 / $44.33 / $44.33
| Facility | 26 | $44.33 | $44.33 | $44.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.97 / $163.85 / $590.00
| Professional | | $130.97 | $163.85 | $590.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.84 / $209.49 / $328.51
| Professional | | $158.84 | $209.49 | $328.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $98.65 / $167.13
| Professional | | $32.34 | $98.65 | $167.13 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $878.86 / $878.86 / $878.86
| Facility | 26 | $878.86 | $878.86 | $878.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $246.33 / $329.56 / $409.06
| Professional | | $246.33 | $329.56 | $409.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.63 / $176.27 / $241.16
| Professional | | $134.63 | $176.27 | $241.16 |