- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $53.84 / $56.53 / $56.53
| Facility | 26 | $53.84 | $56.53 | $56.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.22 / $221.81 / $221.81
| Professional | | $162.22 | $221.81 | $221.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $230.23 / $310.35 / $459.13
| Professional | | $230.23 | $310.35 | $459.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $215.39 / $321.20 / $516.39
| Professional | | $215.39 | $321.20 | $516.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $390.79 / $390.79 / $417.67
| Professional | | $390.79 | $390.79 | $417.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.24 / $333.76 / $415.07
| Professional | | $211.24 | $333.76 | $415.07 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $53.84 / $85.07 / $104.99
| Professional | 26 | $53.84 | $85.07 | $104.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $240.96 / $381.08 / $583.75
| Professional | | $240.96 | $381.08 | $583.75 |