- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $61.55 / $61.55 / $118.84
| Facility | 26 | $61.55 | $61.55 | $118.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.40 / $102.43 / $201.17
| Professional | | $83.40 | $102.43 | $201.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.58 / $128.58 / $128.58
| Professional | | $128.58 | $128.58 | $128.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.21 / $134.47 / $285.17
| Professional | | $89.21 | $134.47 | $285.17 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $120.14 / $120.14 / $120.14
| Facility | 26 | $120.14 | $120.14 | $120.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.69 / $130.28 / $584.30
| Professional | | $102.69 | $130.28 | $584.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.94 / $121.06 / $228.23
| Professional | | $98.94 | $121.06 | $228.23 |