- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $35.72 / $35.72 / $35.72
| Facility | 26 | $35.72 | $35.72 | $35.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.27 / $46.88 / $64.38
| Professional | | $33.27 | $46.88 | $64.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.65 / $50.20 / $59.24
| Professional | | $36.65 | $50.20 | $59.24 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $30.21 / $30.21 / $30.21
| Facility | 26 | $30.21 | $30.21 | $30.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.26 / $57.43 / $141.53
| Professional | | $38.26 | $57.43 | $141.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.14 / $49.21 / $74.84
| Professional | | $37.14 | $49.21 | $74.84 |