- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $51.29 / $51.29 / $51.29
| Facility | 26 | $51.29 | $51.29 | $51.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $229.09 / $323.59
| Professional | | $181.97 | $229.09 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.09 / $309.03 / $416.87
| Professional | | $229.09 | $309.03 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $60.26 / $398.11
| Professional | | $32.36 | $60.26 | $398.11 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $891.25 / $891.25 / $891.25
| Facility | 26 | $891.25 | $891.25 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $457.09 / $489.78
| Professional | | $316.23 | $457.09 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $323.59 / $549.54
| Professional | | $218.78 | $323.59 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $251.19 / $389.05
| Professional | | $60.26 | $251.19 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $251.19 / $398.11
| Professional | | $204.17 | $251.19 | $398.11 |