- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $112.36 / $112.36 / $112.36
| Facility | 26 | $112.36 | $112.36 | $112.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.40 / $147.58 / $147.58
| Professional | | $112.40 | $147.58 | $147.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.56 / $206.73 / $299.75
| Professional | | $145.56 | $206.73 | $299.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $193.26 / $318.68 / $451.99
| Professional | | $193.26 | $318.68 | $451.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.64 / $317.48 / $592.89
| Professional | | $166.64 | $317.48 | $592.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.07 / $192.79 / $713.35
| Professional | | $152.07 | $192.79 | $713.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.85 / $138.82 / $209.65
| Professional | | $118.85 | $138.82 | $209.65 |