- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $43.65 / $43.65 / $43.65
| Facility | 26 | $43.65 | $43.65 | $43.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.28 / $109.65 / $151.36
| Professional | | $81.28 | $109.65 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.13 / $117.49 / $204.17
| Professional | | $89.13 | $117.49 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.44 / $147.91 / $245.47
| Professional | | $72.44 | $147.91 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $158.49 / $309.03
| Professional | | $112.20 | $158.49 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $114.82 / $229.09
| Professional | | $79.43 | $114.82 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.72 / $144.54 / $245.47
| Professional | | $97.72 | $144.54 | $245.47 |