- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $65.34 / $65.34 / $65.34
| Facility | 26 | $65.34 | $65.34 | $65.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.86 / $141.52 / $285.79
| Professional | | $110.86 | $141.52 | $285.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.23 / $210.18 / $320.47
| Professional | | $167.23 | $210.18 | $320.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.81 / $216.57 / $349.07
| Professional | | $133.81 | $216.57 | $349.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.91 / $223.41 / $396.53
| Professional | | $145.91 | $223.41 | $396.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.87 / $161.60 / $299.99
| Professional | | $119.87 | $161.60 | $299.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.09 / $193.01 / $350.90
| Professional | | $135.09 | $193.01 | $350.90 |