- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $63.05 / $63.05 / $132.99
| Facility | 26 | $63.05 | $63.05 | $132.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.29 / $137.41 / $224.39
| Professional | | $100.29 | $137.41 | $224.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.06 / $123.33 / $206.67
| Professional | | $75.06 | $123.33 | $206.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.47 / $214.94 / $251.03
| Professional | | $159.47 | $214.94 | $251.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $46.95 / $155.60
| Professional | | $32.34 | $46.95 | $155.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.47 / $209.45 / $251.03
| Professional | | $159.47 | $209.45 | $251.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.25 / $130.59 / $275.87
| Professional | | $120.25 | $130.59 | $275.87 |