- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $46.28 / $47.27 / $47.27
| Facility | 26 | $46.28 | $47.27 | $47.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.20 / $104.92 / $123.19
| Professional | | $90.20 | $104.92 | $123.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.72 / $111.30 / $152.83
| Professional | | $52.72 | $111.30 | $152.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.01 / $114.34 / $157.68
| Professional | | $80.01 | $114.34 | $157.68 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $115.42 / $225.58 / $225.58
| Facility | 26 | $115.42 | $225.58 | $225.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.03 / $128.84 / $803.29
| Professional | | $95.03 | $128.84 | $803.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.03 / $119.02 / $204.42
| Professional | | $95.03 | $119.02 | $204.42 |