- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $28.86 / $28.86 / $47.18
| Facility | 26 | $28.86 | $28.86 | $47.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $59.67 / $70.40 / $114.32
| Professional | | $59.67 | $70.40 | $114.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.44 / $167.15 / $175.30
| Professional | | $135.44 | $167.15 | $175.30 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $31.61 / $31.61 / $31.61
| Facility | 26 | $31.61 | $31.61 | $31.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.33 / $131.94 / $181.61
| Professional | | $81.33 | $131.94 | $181.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.70 / $138.37 / $542.40
| Professional | | $74.70 | $138.37 | $542.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.13 / $131.47 / $186.30
| Professional | | $81.13 | $131.47 | $186.30 |