- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $92.22 / $92.22 / $92.22
| Facility | 26 | $92.22 | $92.22 | $92.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.84 / $154.91 / $178.90
| Professional | | $140.84 | $154.91 | $178.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.65 / $158.34 / $270.08
| Professional | | $142.65 | $158.34 | $270.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.86 / $228.86 / $347.17
| Professional | | $176.86 | $228.86 | $347.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.51 / $183.60 / $322.64
| Professional | | $154.51 | $183.60 | $322.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.84 / $157.15 / $208.46
| Professional | | $140.84 | $157.15 | $208.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.83 / $227.63 / $331.57
| Professional | | $167.83 | $227.63 | $331.57 |