- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $20.95 / $20.95 / $20.95
| Facility | 26 | $20.95 | $20.95 | $20.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $59.75 / $83.81 / $154.10
| Professional | | $59.75 | $83.81 | $154.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.98 / $123.34 / $171.34
| Professional | | $87.98 | $123.34 | $171.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $68.39 / $123.67 / $222.48
| Professional | | $68.39 | $123.67 | $222.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.30 / $117.73 / $199.00
| Professional | | $95.30 | $117.73 | $199.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.90 / $82.91 / $154.10
| Professional | | $56.90 | $82.91 | $154.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $82.13 / $130.85 / $194.82
| Professional | | $82.13 | $130.85 | $194.82 |