- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $57.54 / $57.54 / $57.54
| Facility | 26 | $57.54 | $57.54 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $204.17 / $426.58
| Professional | | $173.78 | $204.17 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $269.15 / $398.11
| Professional | | $177.83 | $269.15 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $33.11 / $213.80
| Professional | | $32.36 | $33.11 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $316.23 / $457.09
| Professional | | $204.17 | $316.23 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $288.40 / $416.87
| Professional | | $186.21 | $288.40 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.13 / $190.55 / $338.84
| Professional | | $74.13 | $190.55 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $229.09 / $346.74
| Professional | | $151.36 | $229.09 | $346.74 |