- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $42.66 / $154.88 / $162.18
| Facility | 26 | $42.66 | $154.88 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $66.07 / $91.20 / $194.98
| Professional | | $66.07 | $91.20 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $66.07 / $89.13 / $117.49
| Professional | | $66.07 | $89.13 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.70 / $83.18 / $173.78
| Professional | | $53.70 | $83.18 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.61 / $102.33 / $181.97
| Professional | | $67.61 | $102.33 | $181.97 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $181.97 / $181.97 / $181.97
| Facility | 26 | $181.97 | $181.97 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $870.96 / $870.96
| Professional | | $676.08 | $870.96 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.66 / $95.50 / $151.36
| Professional | | $61.66 | $95.50 | $151.36 |