- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $21.55 / $21.55 / $21.90
| Facility | 26 | $21.55 | $21.55 | $21.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $68.48 / $80.66 / $153.46
| Professional | | $68.48 | $80.66 | $153.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.84 / $123.41 / $178.68
| Professional | | $88.84 | $123.41 | $178.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.95 / $129.43 / $219.91
| Professional | | $80.95 | $129.43 | $219.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.71 / $134.41 / $242.50
| Professional | | $111.71 | $134.41 | $242.50 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $21.55 / $21.55 / $21.90
| Facility | 26 | $21.55 | $21.55 | $21.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.84 / $102.43 / $172.02
| Professional | | $71.84 | $102.43 | $172.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.38 / $105.78 / $213.22
| Professional | | $84.38 | $105.78 | $213.22 |