- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $58.85 / $58.85 / $58.85
| Facility | 26 | $58.85 | $58.85 | $58.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.25 / $164.55 / $239.53
| Professional | | $149.25 | $164.55 | $239.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $62.47 / $65.98 / $324.58
| Professional | | $62.47 | $65.98 | $324.58 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $67.42 / $67.42 / $67.42
| Facility | 26 | $67.42 | $67.42 | $67.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $321.43 / $371.49 / $800.14
| Professional | | $321.43 | $371.49 | $800.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.71 / $351.54 / $493.60
| Professional | | $223.71 | $351.54 | $493.60 |