- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $50.12 / $50.12 / $50.12
| Facility | 26 | $50.12 | $50.12 | $50.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.62 / $117.49 / $234.42
| Professional | | $77.62 | $117.49 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $169.82 / $239.88
| Professional | | $109.65 | $169.82 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $33.11 / $114.82
| Professional | | $32.36 | $33.11 | $114.82 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $1,288.25
| Facility | 26 | $1,288.25 | $1,288.25 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $194.98 / $281.84
| Professional | | $162.18 | $194.98 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $169.82 / $239.88
| Professional | | $107.15 | $169.82 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.66 / $112.20 / $218.78
| Professional | | $61.66 | $112.20 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $131.83 / $223.87
| Professional | | $100.00 | $131.83 | $223.87 |