- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $38.29 / $39.35 / $39.35
| Facility | 26 | $38.29 | $39.35 | $39.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.17 / $102.81 / $146.46
| Professional | | $87.17 | $102.81 | $146.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.54 / $121.05 / $169.77
| Professional | | $93.54 | $121.05 | $169.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.71 / $130.82 / $198.22
| Professional | | $105.71 | $130.82 | $198.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.41 / $129.88 / $192.42
| Professional | | $108.41 | $129.88 | $192.42 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $38.29 / $38.29 / $39.35
| Facility | 26 | $38.29 | $38.29 | $39.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.17 / $102.81 / $166.66
| Professional | | $87.17 | $102.81 | $166.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.75 / $127.80 / $212.54
| Professional | | $85.75 | $127.80 | $212.54 |