- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $56.23 / $56.23 / $56.23
| Facility | 26 | $56.23 | $56.23 | $56.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $208.93 / $323.59
| Professional | | $177.83 | $208.93 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $213.80 / $380.19
| Professional | | $173.78 | $213.80 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $275.42 / $489.78
| Professional | | $144.54 | $275.42 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $295.12 / $562.34
| Professional | | $208.93 | $295.12 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $223.87 / $457.09
| Professional | | $173.78 | $223.87 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $295.12 / $436.52
| Professional | | $190.55 | $295.12 | $436.52 |