- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $22.61 / $22.61 / $22.61
| Facility | 26 | $22.61 | $22.61 | $22.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.91 / $208.47 / $226.33
| Professional | | $170.91 | $208.47 | $226.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.26 / $25.26 / $25.26
| Professional | | $25.26 | $25.26 | $25.26 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $25.57 / $25.57 / $25.57
| Facility | 26 | $25.57 | $25.57 | $25.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $160.35 / $264.11 / $1,038.36
| Professional | | $160.35 | $264.11 | $1,038.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.95 / $174.10 / $334.70
| Professional | | $93.95 | $174.10 | $334.70 |