- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $33.88 / $33.88 / $58.88
| Facility | 26 | $33.88 | $33.88 | $58.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $181.97 / $263.03
| Professional | | $147.91 | $181.97 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $263.03 / $263.03
| Professional | | $263.03 | $263.03 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $269.15 / $398.11
| Professional | | $169.82 | $269.15 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $32.36 / $33.11
| Professional | | $32.36 | $32.36 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $190.55 / $302.00
| Professional | | $131.83 | $190.55 | $302.00 |