- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $25.70 / $25.70 / $46.77
| Facility | 26 | $25.70 | $25.70 | $46.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $95.50 / $154.88
| Professional | | $79.43 | $95.50 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.49 / $117.49 / $117.49
| Professional | | $117.49 | $117.49 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $66.07 / $117.49 / $181.97
| Professional | | $66.07 | $117.49 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $32.36 / $33.11
| Professional | | $32.36 | $32.36 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.13 / $97.72 / $169.82
| Professional | | $74.13 | $97.72 | $169.82 |