- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $30.30 / $30.30 / $30.30
| Facility | 26 | $30.30 | $30.30 | $30.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.41 / $169.67 / $169.67
| Professional | | $135.41 | $169.67 | $169.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.84 / $196.63 / $571.58
| Professional | | $151.84 | $196.63 | $571.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.50 / $190.68 / $571.58
| Professional | | $124.50 | $190.68 | $571.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.37 / $190.68 / $358.86
| Professional | | $112.37 | $190.68 | $358.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $99.57 / $172.44 / $553.54
| Professional | | $99.57 | $172.44 | $553.54 |