- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $60.54 / $60.54 / $72.98
| Facility | 26 | $60.54 | $60.54 | $72.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.38 / $123.97 / $192.41
| Professional | | $88.38 | $123.97 | $192.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.78 / $190.78 / $190.78
| Professional | | $190.78 | $190.78 | $190.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.48 / $128.80 / $203.84
| Professional | | $109.48 | $128.80 | $203.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.42 / $122.98 / $198.26
| Professional | | $88.42 | $122.98 | $198.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.40 / $119.02 / $201.75
| Professional | | $81.40 | $119.02 | $201.75 |