- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $71.28 / $71.28 / $71.28
| Facility | 26 | $71.28 | $71.28 | $71.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.93 / $154.68 / $188.50
| Professional | | $94.93 | $154.68 | $188.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.64 / $128.28 / $151.37
| Professional | | $93.64 | $128.28 | $151.37 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $62.11 / $62.11 / $62.65
| Facility | 26 | $62.11 | $62.11 | $62.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.14 / $165.85 / $436.34
| Professional | | $93.14 | $165.85 | $436.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $99.88 / $126.51 / $454.49
| Professional | | $99.88 | $126.51 | $454.49 |