- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $40.84 / $40.84 / $40.84
| Facility | 26 | $40.84 | $40.84 | $40.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.59 / $126.38 / $203.30
| Professional | | $113.59 | $126.38 | $203.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.38 / $134.57 / $221.90
| Professional | | $114.38 | $134.57 | $221.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.19 / $166.94 / $262.24
| Professional | | $110.19 | $166.94 | $262.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.97 / $168.90 / $250.21
| Professional | | $140.97 | $168.90 | $250.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.59 / $135.47 / $218.58
| Professional | | $113.59 | $135.47 | $218.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.33 / $162.34 / $238.52
| Professional | | $112.33 | $162.34 | $238.52 |