- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $37.58 / $37.58 / $56.37
| Facility | 26 | $37.58 | $37.58 | $56.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.25 / $109.57 / $118.93
| Professional | | $67.25 | $109.57 | $118.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.43 / $118.36 / $131.51
| Professional | | $89.43 | $118.36 | $131.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.51 / $62.97 / $114.17
| Professional | | $27.51 | $62.97 | $114.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.70 / $122.73 / $171.28
| Professional | | $75.70 | $122.73 | $171.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.53 / $107.54 / $167.15
| Professional | | $86.53 | $107.54 | $167.15 |