- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $56.40 / $199.06 / $310.60
| Facility | 26 | $56.40 | $199.06 | $310.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.41 / $151.56 / $427.06
| Professional | | $107.41 | $151.56 | $427.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.07 / $253.15 / $391.02
| Professional | | $119.07 | $253.15 | $391.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.69 / $189.63 / $321.62
| Professional | | $131.69 | $189.63 | $321.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.62 / $161.33 / $184.51
| Professional | | $138.62 | $161.33 | $184.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.34 / $97.07 / $194.80
| Professional | | $93.34 | $97.07 | $194.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.21 / $181.64 / $278.93
| Professional | | $108.21 | $181.64 | $278.93 |