- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $35.09 / $36.84 / $36.84
| Facility | 26 | $35.09 | $36.84 | $36.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.75 / $181.38 / $215.86
| Professional | | $132.75 | $181.38 | $215.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $187.51 / $253.86 / $370.75
| Professional | | $187.51 | $253.86 | $370.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.71 / $245.18 / $387.00
| Professional | | $159.71 | $245.18 | $387.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $319.57 / $319.57 / $342.62
| Professional | | $319.57 | $319.57 | $342.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.74 / $272.93 / $340.92
| Professional | | $172.74 | $272.93 | $340.92 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $35.09 / $55.44 / $68.43
| Professional | 26 | $35.09 | $55.44 | $68.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.37 / $286.91 / $478.18
| Professional | | $161.37 | $286.91 | $478.18 |