- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $52.48 / $52.48 / $52.48
| Facility | 26 | $52.48 | $52.48 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.18 / $97.72 / $194.98
| Professional | | $83.18 | $97.72 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.10 / $87.10 / $131.83
| Professional | | $87.10 | $87.10 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.44 / $95.50 / $134.90
| Professional | | $72.44 | $95.50 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.72 / $117.49 / $186.21
| Professional | | $97.72 | $117.49 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $32.36 / $33.11
| Professional | | $32.36 | $32.36 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.18 / $102.33 / $162.18
| Professional | | $83.18 | $102.33 | $162.18 |