- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $27.62 / $34.11 / $68.12
| Facility | 26 | $27.62 | $34.11 | $68.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $59.62 / $89.35 / $173.02
| Professional | | $59.62 | $89.35 | $173.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.86 / $96.79 / $194.87
| Professional | | $69.86 | $96.79 | $194.87 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $32.78 / $32.78 / $32.78
| Facility | 26 | $32.78 | $32.78 | $32.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.07 / $114.87 / $203.27
| Professional | | $74.07 | $114.87 | $203.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $62.92 / $102.09 / $174.57
| Professional | | $62.92 | $102.09 | $174.57 |