- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $35.97 / $35.97 / $60.70
| Facility | 26 | $35.97 | $35.97 | $60.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.74 / $65.41 / $161.71
| Professional | | $58.74 | $65.41 | $161.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.34 / $175.43 / $249.11
| Professional | | $140.34 | $175.43 | $249.11 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $210.51 / $263.14 / $373.66
| Professional | 50 | $210.51 | $263.14 | $373.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.41 / $39.51 / $77.54
| Professional | | $27.41 | $39.51 | $77.54 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $43.74 / $43.74 / $43.74
| Facility | 26 | $43.74 | $43.74 | $43.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.95 / $174.83 / $310.98
| Professional | | $71.95 | $174.83 | $310.98 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $143.59 / $143.59 / $164.79
| Professional | 50 | $143.59 | $143.59 | $164.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.47 / $144.25 / $216.13
| Professional | | $81.47 | $144.25 | $216.13 |