- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $30.58 / $30.58 / $30.58
| Facility | 26 | $30.58 | $30.58 | $30.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.56 / $142.56 / $156.11
| Professional | | $142.56 | $142.56 | $156.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.18 / $163.69 / $270.77
| Professional | | $153.18 | $163.69 | $270.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.72 / $208.66 / $361.69
| Professional | | $153.72 | $208.66 | $361.69 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $56.85 / $68.00 / $120.48
| Facility | 26 | $56.85 | $68.00 | $120.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $307.55 / $307.55 / $307.55
| Professional | | $307.55 | $307.55 | $307.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.02 / $142.97 / $196.89
| Professional | | $41.02 | $142.97 | $196.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.51 / $201.91 / $331.51
| Professional | | $166.51 | $201.91 | $331.51 |