- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $33.88 / $33.88 / $33.88
| Facility | 26 | $33.88 | $33.88 | $33.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.62 / $97.72 / $190.55
| Professional | | $77.62 | $97.72 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.33 / $131.83 / $177.83
| Professional | | $93.33 | $131.83 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.72 / $125.89 / $208.93
| Professional | | $97.72 | $125.89 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $147.91 / $263.03
| Professional | | $112.20 | $147.91 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $109.65 / $204.17
| Professional | | $79.43 | $109.65 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.10 / $134.90 / $263.03
| Professional | | $87.10 | $134.90 | $263.03 |