- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $87.93 / $155.63 / $354.56
| Facility | 26 | $87.93 | $155.63 | $354.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.93 / $135.84 / $203.03
| Professional | | $107.93 | $135.84 | $203.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.78 / $182.10 / $305.08
| Professional | | $110.78 | $182.10 | $305.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.83 / $185.29 / $428.92
| Professional | | $113.83 | $185.29 | $428.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.57 / $172.70 / $253.26
| Professional | | $134.57 | $172.70 | $253.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.93 / $194.34 / $412.93
| Professional | | $116.93 | $194.34 | $412.93 |