- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $57.44 / $57.44 / $57.44
| Facility | 26 | $57.44 | $57.44 | $57.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $254.71 / $307.63 / $307.63
| Professional | | $254.71 | $307.63 | $307.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $260.70 / $382.77 / $555.01
| Professional | | $260.70 | $382.77 | $555.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $348.83 / $658.26 / $1,044.43
| Professional | | $348.83 | $658.26 | $1,044.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $303.56 / $530.41 / $1,205.61
| Professional | | $303.56 | $530.41 | $1,205.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.22 / $397.53 / $568.63
| Professional | | $380.22 | $397.53 | $568.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $249.71 / $291.66 / $440.49
| Professional | | $249.71 | $291.66 | $440.49 |