- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $34.67 / $34.67 / $61.66
| Facility | 26 | $34.67 | $34.67 | $61.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.88 / $77.62 / $162.18
| Professional | | $58.88 | $77.62 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $85.11 / $85.11 / $85.11
| Professional | 50 | $85.11 | $85.11 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $251.19 / $251.19
| Professional | | $251.19 | $251.19 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.48 / $141.25 / $275.42
| Professional | | $52.48 | $141.25 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.62 / $32.36 / $33.11
| Professional | | $31.62 | $32.36 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.62 / $114.82 / $245.47
| Professional | | $77.62 | $114.82 | $245.47 |