- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $25.25 / $25.25 / $39.61
| Facility | 26 | $25.25 | $25.25 | $39.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.22 / $59.90 / $78.59
| Professional | | $52.22 | $59.90 | $78.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.04 / $144.43 / $153.35
| Professional | | $117.04 | $144.43 | $153.35 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $28.43 / $28.43 / $28.43
| Facility | 26 | $28.43 | $28.43 | $28.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $62.08 / $102.27 / $156.29
| Professional | | $62.08 | $102.27 | $156.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.27 / $108.49 / $393.85
| Professional | | $60.27 | $108.49 | $393.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.27 / $101.84 / $150.51
| Professional | | $60.27 | $101.84 | $150.51 |