- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $41.69 / $42.66 / $42.66
| Facility | 26 | $41.69 | $42.66 | $42.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $181.97 / $263.03
| Professional | | $141.25 | $181.97 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.70 / $257.04 / $257.04
| Professional | | $53.70 | $257.04 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.88 / $251.19 / $416.87
| Professional | | $154.88 | $251.19 | $416.87 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $32.36 / $79.43 / $89.13
| Facility | 26 | $32.36 | $79.43 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $190.55 / $263.03
| Professional | | $151.36 | $190.55 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.88 / $194.98 / $416.87
| Professional | | $154.88 | $194.98 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $194.98 / $263.03
| Professional | | $158.49 | $194.98 | $263.03 |