- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $32.36 / $32.36 / $32.36
| Facility | 26 | $32.36 | $32.36 | $32.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $66.07 / $107.15 / $562.34
| Professional | | $66.07 | $107.15 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $109.65 / $190.55
| Professional | | $60.26 | $109.65 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $33.11 / $91.20
| Professional | | $32.36 | $33.11 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $173.78 / $213.80
| Professional | | $141.25 | $173.78 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $141.25 / $199.53
| Professional | | $104.71 | $141.25 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.81 / $107.15 / $181.97
| Professional | | $39.81 | $107.15 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.10 / $95.50 / $125.89
| Professional | | $63.10 | $95.50 | $125.89 |