- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $67.92 / $67.92 / $289.94
| Facility | 26 | $67.92 | $67.92 | $289.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.52 / $143.26 / $190.30
| Professional | | $124.52 | $143.26 | $190.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.97 / $187.66 / $334.83
| Professional | | $122.97 | $187.66 | $334.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.50 / $206.74 / $206.74
| Professional | | $174.50 | $206.74 | $206.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $82.86 / $121.69 / $196.13
| Professional | | $82.86 | $121.69 | $196.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.78 / $176.54 / $294.11
| Professional | | $115.78 | $176.54 | $294.11 |