- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $45.21 / $45.21 / $103.66
| Facility | 26 | $45.21 | $45.21 | $103.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.34 / $196.53 / $268.10
| Professional | | $157.34 | $196.53 | $268.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $528.65 / $621.94 / $684.16
| Professional | | $528.65 | $621.94 | $684.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $356.48 / $356.48 / $579.15
| Professional | | $356.48 | $356.48 | $579.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.90 / $487.35 / $620.62
| Professional | | $168.90 | $487.35 | $620.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.77 / $312.08 / $620.62
| Professional | | $162.77 | $312.08 | $620.62 |