- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $58.88 / $58.88 / $58.88
| Facility | 26 | $58.88 | $58.88 | $58.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.18 / $102.33 / $218.78
| Professional | | $83.18 | $102.33 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $134.90 / $218.78
| Professional | | $114.82 | $134.90 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $33.11 / $213.80
| Professional | | $32.36 | $33.11 | $213.80 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $251.19 / $251.19 / $251.19
| Facility | 26 | $251.19 | $251.19 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.72 / $141.25 / $194.98
| Professional | | $97.72 | $141.25 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.13 / $144.54 / $218.78
| Professional | | $89.13 | $144.54 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.12 / $83.18 / $165.96
| Professional | | $50.12 | $83.18 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.18 / $112.20 / $165.96
| Professional | | $83.18 | $112.20 | $165.96 |