- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $52.84 / $52.84 / $52.84
| Facility | 26 | $52.84 | $52.84 | $52.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.38 / $114.48 / $153.94
| Professional | | $88.38 | $114.48 | $153.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $210.54 / $256.05 / $281.66
| Professional | | $210.54 | $256.05 | $281.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.68 / $235.76 / $368.42
| Professional | | $104.68 | $235.76 | $368.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.70 / $223.05 / $803.29
| Professional | | $122.70 | $223.05 | $803.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.70 / $222.05 / $290.42
| Professional | | $122.70 | $222.05 | $290.42 |