- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $97.72 / $97.72 / $97.72
| Facility | 26 | $97.72 | $97.72 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $141.25 / $275.42
| Professional | | $104.71 | $141.25 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $190.55 / $245.47
| Professional | | $125.89 | $190.55 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $60.26 / $234.42
| Professional | | $32.36 | $60.26 | $234.42 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $457.09 / $457.09 / $457.09
| Facility | 26 | $457.09 | $457.09 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $234.42 / $281.84
| Professional | | $199.53 | $234.42 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $208.93 / $338.84
| Professional | | $125.89 | $208.93 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $66.07 / $125.89 / $251.19
| Professional | | $66.07 | $125.89 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $141.25 / $234.42
| Professional | | $120.23 | $141.25 | $234.42 |