- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $51.29 / $51.29 / $51.29
| Facility | 26 | $51.29 | $51.29 | $51.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.96 / $194.98 / $239.88
| Professional | | $165.96 | $194.98 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.88 / $58.88 / $58.88
| Professional | | $58.88 | $58.88 | $58.88 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $12.59 / $58.88 / $85.11
| Facility | 26 | $12.59 | $58.88 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $269.15 / $851.14
| Professional | | $158.49 | $269.15 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $169.82 / $263.03
| Professional | | $123.03 | $169.82 | $263.03 |