- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $23.56 / $24.74 / $24.74
| Facility | 26 | $23.56 | $24.74 | $24.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.42 / $141.97 / $191.19
| Professional | | $103.42 | $141.97 | $191.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.15 / $204.72 / $291.45
| Professional | | $147.15 | $204.72 | $291.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $59.93 / $122.13 / $247.93
| Professional | | $59.93 | $122.13 | $247.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.14 / $250.14 / $269.08
| Professional | | $250.14 | $250.14 | $269.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $175.77 / $219.04 / $297.45
| Professional | | $175.77 | $219.04 | $297.45 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $30.63 / $38.17 / $51.83
| Professional | 26 | $30.63 | $38.17 | $51.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.73 / $219.48 / $475.52
| Professional | | $69.73 | $219.48 | $475.52 |