- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $48.57 / $59.64 / $104.85
| Facility | 26 | $48.57 | $59.64 | $104.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.85 / $130.10 / $337.71
| Professional | | $100.85 | $130.10 | $337.71 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $58.74 / $58.74 / $58.74
| Facility | 26 | $58.74 | $58.74 | $58.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.58 / $138.63 / $227.60
| Professional | | $108.58 | $138.63 | $227.60 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $57.04 / $57.04 / $57.04
| Facility | 26 | $57.04 | $57.04 | $57.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.26 / $155.47 / $263.87
| Professional | | $104.26 | $155.47 | $263.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.16 / $131.85 / $228.34
| Professional | | $108.16 | $131.85 | $228.34 |