- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $21.88 / $42.66 / $107.15
| Facility | 26 | $21.88 | $42.66 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.71 / $57.54 / $109.65
| Professional | | $45.71 | $57.54 | $109.65 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $26.92 / $26.92 / $26.92
| Facility | 26 | $26.92 | $26.92 | $26.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.71 / $70.79 / $131.83
| Professional | | $45.71 | $70.79 | $131.83 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $5.62 / $30.20 / $79.43
| Facility | 26 | $5.62 | $30.20 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.86 / $79.43 / $154.88
| Professional | | $47.86 | $79.43 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.86 / $63.10 / $117.49
| Professional | | $47.86 | $63.10 | $117.49 |