- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $39.28 / $43.16 / $43.16
| Facility | 26 | $39.28 | $43.16 | $43.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.16 / $156.79 / $229.01
| Professional | | $144.16 | $156.79 | $229.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $247.37 / $291.02 / $291.02
| Professional | | $247.37 | $291.02 | $291.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $171.45 / $295.55 / $484.34
| Professional | | $171.45 | $295.55 | $484.34 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $104.43 / $104.43 / $233.70
| Facility | 26 | $104.43 | $104.43 | $233.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $205.35 / $291.20 / $1,494.48
| Professional | | $205.35 | $291.20 | $1,494.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.16 / $233.07 / $352.37
| Professional | | $198.16 | $233.07 | $352.37 |