- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $50.69 / $50.69 / $50.69
| Facility | 26 | $50.69 | $50.69 | $50.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.41 / $225.53 / $274.52
| Professional | | $147.41 | $225.53 | $274.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.91 / $278.89 / $401.25
| Professional | | $203.91 | $278.89 | $401.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.10 / $301.95 / $442.74
| Professional | | $204.10 | $301.95 | $442.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $311.22 / $378.25 / $526.67
| Professional | | $311.22 | $378.25 | $526.67 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $59.37 / $73.98 / $100.47
| Professional | 26 | $59.37 | $73.98 | $100.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $214.54 / $341.40 / $532.04
| Professional | | $214.54 | $341.40 | $532.04 |