- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $58.88 / $58.88 / $58.88
| Facility | 26 | $58.88 | $58.88 | $58.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.50 / $134.90 / $302.00
| Professional | | $95.50 | $134.90 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $169.82 / $223.87
| Professional | | $109.65 | $169.82 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $165.96 / $269.15
| Professional | | $114.82 | $165.96 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.90 / $186.21 / $346.74
| Professional | | $134.90 | $186.21 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $158.49 / $302.00
| Professional | | $109.65 | $158.49 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $169.82 / $338.84
| Professional | | $109.65 | $169.82 | $338.84 |