- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $58.26 / $58.26 / $61.47
| Facility | 26 | $58.26 | $58.26 | $61.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.34 / $129.93 / $151.03
| Professional | | $108.34 | $129.93 | $151.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $231.61 / $231.61 / $231.61
| Professional | | $231.61 | $231.61 | $231.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $99.04 / $126.90 / $206.03
| Professional | | $99.04 | $126.90 | $206.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.39 / $72.15 / $142.63
| Professional | | $56.39 | $72.15 | $142.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $99.32 / $152.91 / $271.00
| Professional | | $99.32 | $152.91 | $271.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.11 / $136.93 / $231.23
| Professional | | $101.11 | $136.93 | $231.23 |