- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $52.86 / $52.86 / $85.61
| Facility | 26 | $52.86 | $52.86 | $85.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.07 / $121.48 / $183.50
| Professional | | $110.07 | $121.48 | $183.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.08 / $288.87 / $301.93
| Professional | | $234.08 | $288.87 | $301.93 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $57.04 / $57.04 / $57.04
| Facility | 26 | $57.04 | $57.04 | $57.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.90 / $205.69 / $313.45
| Professional | | $124.90 | $205.69 | $313.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.46 / $224.82 / $735.51
| Professional | | $120.46 | $224.82 | $735.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.18 / $202.72 / $299.47
| Professional | | $120.18 | $202.72 | $299.47 |