- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $151.36 / $151.36 / $151.36
| Facility | 26 | $151.36 | $151.36 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $177.83 / $223.87
| Professional | | $120.23 | $177.83 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $251.19 / $354.81
| Professional | | $169.82 | $251.19 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $407.38 / $537.03
| Professional | | $218.78 | $407.38 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $331.13 / $602.56
| Professional | | $190.55 | $331.13 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $239.88 / $676.08
| Professional | | $169.82 | $239.88 | $676.08 |