- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $67.61 / $67.61 / $67.61
| Facility | 26 | $67.61 | $67.61 | $67.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $144.54 / $275.42
| Professional | | $112.20 | $144.54 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.90 / $208.93 / $309.03
| Professional | | $134.90 | $208.93 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $181.97 / $346.74
| Professional | | $107.15 | $181.97 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.88 / $239.88 / $371.54
| Professional | | $154.88 | $239.88 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.28 / $177.83 / $630.96
| Professional | | $81.28 | $177.83 | $630.96 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $15.14 / $17.78 / $17.78
| Facility | 26 | $15.14 | $17.78 | $17.78 |