- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $52.48 / $52.48 / $52.48
| Facility | 26 | $52.48 | $52.48 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $194.98 / $302.00
| Professional | | $169.82 | $194.98 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $204.17 / $323.59
| Professional | | $144.54 | $204.17 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.67 / $44.67 / $44.67
| Professional | | $44.67 | $44.67 | $44.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $204.17 / $363.08
| Professional | | $141.25 | $204.17 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $204.17 / $338.84
| Professional | | $144.54 | $204.17 | $338.84 |