- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $71.65 / $71.65 / $71.65
| Facility | 26 | $71.65 | $71.65 | $71.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $99.20 / $133.51 / $192.40
| Professional | | $99.20 | $133.51 | $192.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.57 / $133.66 / $157.72
| Professional | | $97.57 | $133.66 | $157.72 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $64.73 / $64.73 / $65.30
| Facility | 26 | $64.73 | $64.73 | $65.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.16 / $174.98 / $451.01
| Professional | | $100.16 | $174.98 | $451.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.10 / $141.59 / $468.49
| Professional | | $108.10 | $141.59 | $468.49 |