- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $81.31 / $81.31 / $402.65
| Facility | 26 | $81.31 | $81.31 | $402.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.66 / $209.40 / $315.58
| Professional | | $157.66 | $209.40 | $315.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.24 / $314.44 / $490.93
| Professional | | $180.24 | $314.44 | $490.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $233.26 / $303.39 / $390.08
| Professional | | $233.26 | $303.39 | $390.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.04 / $213.86 / $292.83
| Professional | | $142.04 | $213.86 | $292.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.87 / $247.48 / $423.86
| Professional | | $162.87 | $247.48 | $423.86 |