- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $80.59 / $80.59 / $80.59
| Facility | 26 | $80.59 | $80.59 | $80.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.00 / $140.84 / $163.12
| Professional | | $129.00 | $140.84 | $163.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.44 / $143.44 / $143.44
| Professional | | $143.44 | $143.44 | $143.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.70 / $143.15 / $196.57
| Professional | | $84.70 | $143.15 | $196.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.97 / $193.40 / $241.74
| Professional | | $133.97 | $193.40 | $241.74 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $198.06 / $383.01 / $383.01
| Facility | 26 | $198.06 | $383.01 | $383.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.68 / $178.40 / $956.27
| Professional | | $130.68 | $178.40 | $956.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.68 / $168.49 / $275.62
| Professional | | $130.68 | $168.49 | $275.62 |