- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $26.35 / $26.35 / $26.35
| Facility | 26 | $26.35 | $26.35 | $26.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.95 / $105.81 / $165.38
| Professional | | $71.95 | $105.81 | $165.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.17 / $120.35 / $189.80
| Professional | | $72.17 | $120.35 | $189.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.85 / $58.93 / $77.63
| Professional | | $45.85 | $58.93 | $77.63 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $198.33 / $198.33 / $198.33
| Facility | 26 | $198.33 | $198.33 | $198.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.46 / $152.77 / $200.95
| Professional | | $121.46 | $152.77 | $200.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.48 / $98.19 / $154.19
| Professional | | $83.48 | $98.19 | $154.19 |