- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $26.67 / $26.67 / $26.67
| Facility | 26 | $26.67 | $26.67 | $26.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.37 / $99.42 / $103.50
| Professional | | $77.37 | $99.42 | $103.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.83 / $112.37 / $155.77
| Professional | | $86.83 | $112.37 | $155.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.16 / $134.96 / $193.08
| Professional | | $73.16 | $134.96 | $193.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.30 / $115.89 / $217.43
| Professional | | $85.30 | $115.89 | $217.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.37 / $99.42 / $117.09
| Professional | | $77.37 | $99.42 | $117.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.57 / $134.88 / $217.43
| Professional | | $85.57 | $134.88 | $217.43 |