- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $48.98 / $48.98 / $48.98
| Facility | 26 | $48.98 | $48.98 | $48.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.18 / $95.50 / $218.78
| Professional | | $83.18 | $95.50 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.29 / $89.13 / $123.03
| Professional | | $51.29 | $89.13 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.20 / $125.89 / $144.54
| Professional | | $91.20 | $125.89 | $144.54 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $120.23 / $234.42 / $234.42
| Facility | 26 | $120.23 | $234.42 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.28 / $109.65 / $588.84
| Professional | | $81.28 | $109.65 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.62 / $102.33 / $158.49
| Professional | | $77.62 | $102.33 | $158.49 |