- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $38.90 / $83.18 / $199.53
| Facility | 26 | $38.90 | $83.18 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.62 / $114.82 / $234.42
| Professional | | $77.62 | $114.82 | $234.42 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $47.86 / $47.86 / $47.86
| Facility | 26 | $47.86 | $47.86 | $47.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.11 / $158.49 / $331.13
| Professional | | $85.11 | $158.49 | $331.13 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $10.47 / $56.23 / $138.04
| Facility | 26 | $10.47 | $56.23 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.13 / $169.82 / $331.13
| Professional | | $89.13 | $169.82 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.50 / $141.25 / $269.15
| Professional | | $95.50 | $141.25 | $269.15 |