- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $59.43 / $59.43 / $59.43
| Facility | 26 | $59.43 | $59.43 | $59.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.20 / $130.10 / $206.86
| Professional | | $110.20 | $130.10 | $206.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.71 / $156.22 / $226.35
| Professional | | $120.71 | $156.22 | $226.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.80 / $173.68 / $255.30
| Professional | | $134.80 | $173.68 | $255.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.82 / $180.11 / $287.68
| Professional | | $145.82 | $180.11 | $287.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.20 / $134.09 / $225.32
| Professional | | $110.20 | $134.09 | $225.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.32 / $167.79 / $242.58
| Professional | | $112.32 | $167.79 | $242.58 |