- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $66.07 / $199.53 / $234.42
| Facility | 26 | $66.07 | $199.53 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.50 / $181.97 / $426.58
| Professional | | $95.50 | $181.97 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.49 / $173.78 / $251.19
| Professional | | $117.49 | $173.78 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $177.83 / $323.59
| Professional | | $131.83 | $177.83 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $151.36 / $190.55
| Professional | | $123.03 | $151.36 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.18 / $83.18 / $194.98
| Professional | | $83.18 | $83.18 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.33 / $134.90 / $234.42
| Professional | | $93.33 | $134.90 | $234.42 |