- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $68.12 / $68.12 / $102.18
| Facility | 26 | $68.12 | $68.12 | $102.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.74 / $102.43 / $190.85
| Professional | | $87.74 | $102.43 | $190.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.31 / $124.31 / $124.31
| Professional | | $124.31 | $124.31 | $124.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.28 / $124.79 / $124.79
| Professional | | $94.28 | $124.79 | $124.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.52 / $130.25 / $167.17
| Professional | | $86.52 | $130.25 | $167.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.96 / $142.96 / $142.96
| Professional | | $142.96 | $142.96 | $142.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.94 / $115.31 / $173.12
| Professional | | $79.94 | $115.31 | $173.12 |