- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $56.63 / $78.78 / $78.78
| Facility | 26 | $56.63 | $78.78 | $78.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.49 / $137.85 / $187.90
| Professional | | $94.49 | $137.85 | $187.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.38 / $197.79 / $233.39
| Professional | | $144.38 | $197.79 | $233.39 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $59.22 / $59.22 / $59.22
| Facility | 26 | $59.22 | $59.22 | $59.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.58 / $160.94 / $387.18
| Professional | | $106.58 | $160.94 | $387.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.06 / $133.22 / $174.96
| Professional | | $102.06 | $133.22 | $174.96 |