- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $140.28 / $140.28 / $146.87
| Facility | 26 | $140.28 | $140.28 | $146.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.51 / $188.81 / $213.13
| Professional | | $167.51 | $188.81 | $213.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $252.45 / $252.45 / $252.45
| Professional | | $252.45 | $252.45 | $252.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.53 / $163.13 / $213.71
| Professional | | $120.53 | $163.13 | $213.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.24 / $143.06 / $210.38
| Professional | | $35.24 | $143.06 | $210.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.07 / $206.09 / $387.51
| Professional | | $117.07 | $206.09 | $387.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.51 / $198.14 / $344.47
| Professional | | $154.51 | $198.14 | $344.47 |