- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $51.28 / $53.84 / $53.84
| Facility | 26 | $51.28 | $53.84 | $53.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.81 / $126.29 / $232.82
| Professional | | $89.81 | $126.29 | $232.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.88 / $182.30 / $284.14
| Professional | | $130.88 | $182.30 | $284.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.78 / $204.29 / $553.28
| Professional | | $111.78 | $204.29 | $553.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $222.52 / $222.52 / $233.12
| Professional | | $222.52 | $222.52 | $233.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $156.36 / $194.85 / $264.62
| Professional | | $156.36 | $194.85 | $264.62 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $66.66 / $83.07 / $112.82
| Professional | 26 | $66.66 | $83.07 | $112.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.13 / $238.63 / $427.89
| Professional | | $154.13 | $238.63 | $427.89 |