- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $18.70 / $21.27 / $30.46
| Facility | 26 | $18.70 | $21.27 | $30.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.84 / $95.95 / $153.46
| Professional | | $71.84 | $95.95 | $153.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.20 / $117.24 / $139.72
| Professional | | $106.20 | $117.24 | $139.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.39 / $87.46 / $153.62
| Professional | | $52.39 | $87.46 | $153.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $59.59 / $89.11 / $134.51
| Professional | | $59.59 | $89.11 | $134.51 |