- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $28.18 / $33.21 / $45.62
| Facility | 26 | $28.18 | $33.21 | $45.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.37 / $136.68 / $221.33
| Professional | | $90.37 | $136.68 | $221.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.15 / $169.06 / $201.18
| Professional | | $152.15 | $169.06 | $201.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.97 / $120.84 / $222.54
| Professional | | $75.97 | $120.84 | $222.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.42 / $125.58 / $185.34
| Professional | | $78.42 | $125.58 | $185.34 |