- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $56.65 / $56.65 / $56.65
| Facility | 26 | $56.65 | $56.65 | $56.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.56 / $100.10 / $144.93
| Professional | | $90.56 | $100.10 | $144.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.72 / $94.13 / $171.68
| Professional | | $85.72 | $94.13 | $171.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.75 / $122.82 / $206.22
| Professional | | $85.75 | $122.82 | $206.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.85 / $114.69 / $193.87
| Professional | | $92.85 | $114.69 | $193.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.48 / $102.43 / $150.22
| Professional | | $91.48 | $102.43 | $150.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.80 / $132.79 / $183.52
| Professional | | $97.80 | $132.79 | $183.52 |