- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $35.64 / $35.64 / $35.64
| Facility | 26 | $35.64 | $35.64 | $35.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.41 / $246.40 / $427.88
| Professional | | $147.41 | $246.40 | $427.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.31 / $137.32 / $459.32
| Professional | | $43.31 | $137.32 | $459.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $188.82 / $288.99 / $421.17
| Professional | | $188.82 | $288.99 | $421.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $66.06 / $274.31
| Professional | | $32.34 | $66.06 | $274.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $217.41 / $363.22 / $503.30
| Professional | | $217.41 | $363.22 | $503.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $217.31 / $352.78 / $479.56
| Professional | | $217.31 | $352.78 | $479.56 |