- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $36.27 / $36.27 / $60.37
| Facility | 26 | $36.27 | $36.27 | $60.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.46 / $253.33 / $267.50
| Professional | | $251.46 | $253.33 | $267.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $246.83 / $308.54 / $425.78
| Professional | | $246.83 | $308.54 | $425.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.95 / $218.67 / $313.99
| Professional | | $37.95 | $218.67 | $313.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $328.37 / $382.96 / $624.86
| Professional | | $328.37 | $382.96 | $624.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $278.61 / $319.94 / $542.07
| Professional | | $278.61 | $319.94 | $542.07 |