- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $100.21 / $100.21 / $100.21
| Facility | 26 | $100.21 | $100.21 | $100.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.90 / $148.82 / $168.46
| Professional | | $137.90 | $148.82 | $168.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $171.04 / $208.43 / $324.16
| Professional | | $171.04 | $208.43 | $324.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.96 / $94.06 / $159.37
| Professional | | $51.96 | $94.06 | $159.37 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $481.30 / $481.30 / $481.30
| Facility | 26 | $481.30 | $481.30 | $481.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.28 / $231.34 / $291.89
| Professional | | $173.28 | $231.34 | $291.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.80 / $184.65 / $273.42
| Professional | | $127.80 | $184.65 | $273.42 |