- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $57.56 / $57.56 / $57.56
| Facility | 26 | $57.56 | $57.56 | $57.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.49 / $102.43 / $105.44
| Professional | | $90.49 | $102.43 | $105.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $226.26 / $328.28 / $328.28
| Professional | | $226.26 | $328.28 | $328.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.31 / $127.88 / $328.28
| Professional | | $72.31 | $127.88 | $328.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.69 / $131.83 / $217.05
| Professional | | $112.69 | $131.83 | $217.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.32 / $143.18 / $396.29
| Professional | | $136.32 | $143.18 | $396.29 |