- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $28.70 / $28.70 / $28.70
| Facility | 26 | $28.70 | $28.70 | $28.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.42 / $64.25 / $342.61
| Professional | | $51.42 | $64.25 | $342.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $62.08 / $80.50 / $119.08
| Professional | | $62.08 | $80.50 | $119.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.09 / $29.53 / $55.49
| Professional | | $23.09 | $29.53 | $55.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.71 / $103.17 / $121.38
| Professional | | $91.71 | $103.17 | $121.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.74 / $60.27 / $97.22
| Professional | | $56.74 | $60.27 | $97.22 |