- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $30.73 / $30.73 / $30.73
| Facility | 26 | $30.73 | $30.73 | $30.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $65.54 / $86.91 / $109.81
| Professional | | $65.54 | $86.91 | $109.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $66.45 / $91.04 / $107.43
| Professional | | $66.45 | $91.04 | $107.43 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $25.92 / $25.92 / $26.15
| Facility | 26 | $25.92 | $25.92 | $26.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.10 / $109.40 / $203.14
| Professional | | $63.10 | $109.40 | $203.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.93 / $84.08 / $111.30
| Professional | | $64.93 | $84.08 | $111.30 |