- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $33.88 / $34.67 / $58.88
| Facility | 26 | $33.88 | $34.67 | $58.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.44 / $93.33 / $204.17
| Professional | | $72.44 | $93.33 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.88 / $204.17 / $223.87
| Professional | | $154.88 | $204.17 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.13 / $134.90 / $229.09
| Professional | | $89.13 | $134.90 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.20 / $162.18 / $575.44
| Professional | | $91.20 | $162.18 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.20 / $144.54 / $223.87
| Professional | | $91.20 | $144.54 | $223.87 |