- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $32.97 / $32.97 / $32.97
| Facility | 26 | $32.97 | $32.97 | $32.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.10 / $184.50 / $220.69
| Professional | | $136.10 | $184.50 | $220.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.39 / $229.08 / $274.89
| Professional | | $46.39 | $229.08 | $274.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.36 / $227.48 / $670.45
| Professional | | $120.36 | $227.48 | $670.45 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $26.09 / $26.09 / $32.97
| Facility | 26 | $26.09 | $26.09 | $32.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.65 / $178.11 / $251.45
| Professional | | $149.65 | $178.11 | $251.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.83 / $143.32 / $216.02
| Professional | | $35.83 | $143.32 | $216.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.62 / $156.81 / $216.32
| Professional | | $106.62 | $156.81 | $216.32 |