- 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
- $165.96 / $194.98 / $288.40
| Professional | | $165.96 | $194.98 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.48 / $199.53 / $275.42
| Professional | | $52.48 | $199.53 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.88 / $213.80 / $323.59
| Professional | | $154.88 | $213.80 | $323.59 |
- 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
- $158.49 / $213.80 / $1,318.26
| Professional | | $158.49 | $213.80 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.88 / $199.53 / $309.03
| Professional | | $154.88 | $199.53 | $309.03 |