- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $41.24 / $41.24 / $41.24
| Facility | 26 | $41.24 | $41.24 | $41.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.63 / $232.64 / $388.53
| Professional | | $192.63 | $232.64 | $388.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $236.49 / $278.23 / $413.30
| Professional | | $236.49 | $278.23 | $413.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $274.11 / $385.99 / $500.83
| Professional | | $274.11 | $385.99 | $500.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.39 / $304.75 / $571.79
| Professional | | $263.39 | $304.75 | $571.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.63 / $256.52 / $449.78
| Professional | | $192.63 | $256.52 | $449.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $224.20 / $334.81 / $444.15
| Professional | | $224.20 | $334.81 | $444.15 |