- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $27.96 / $27.96 / $47.40
| Facility | 26 | $27.96 | $27.96 | $47.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.25 / $209.65 / $223.87
| Professional | | $158.25 | $209.65 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.25 / $163.36 / $231.97
| Professional | | $153.25 | $163.36 | $231.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.26 / $211.55 / $265.64
| Professional | | $32.26 | $211.55 | $265.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $179.45 / $237.59 / $405.59
| Professional | | $179.45 | $237.59 | $405.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.04 / $243.70 / $424.04
| Professional | | $157.04 | $243.70 | $424.04 |