- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $62.85 / $62.85 / $62.85
| Facility | 26 | $62.85 | $62.85 | $62.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $156.11 / $178.18 / $281.54
| Professional | | $156.11 | $178.18 | $281.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $256.02 / $404.89 / $507.24
| Professional | | $256.02 | $404.89 | $507.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $328.73 / $501.43 / $875.06
| Professional | | $328.73 | $501.43 | $875.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $412.61 / $494.35 / $732.34
| Professional | | $412.61 | $494.35 | $732.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $156.11 / $192.15 / $281.54
| Professional | | $156.11 | $192.15 | $281.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.28 / $477.39 / $791.15
| Professional | | $346.28 | $477.39 | $791.15 |