- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $22.91 / $30.20 / $177.83
| Facility | 26 | $22.91 | $30.20 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.66 / $91.20 / $181.97
| Professional | | $61.66 | $91.20 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.84 / $97.72 / $131.83
| Professional | | $28.84 | $97.72 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.98 / $70.79 / $131.83
| Professional | | $48.98 | $70.79 | $131.83 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $66.07 / $66.07 / $125.89
| Facility | 26 | $66.07 | $66.07 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $66.07 / $97.72 / $676.08
| Professional | | $66.07 | $97.72 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $66.07 / $85.11 / $102.33
| Professional | | $66.07 | $85.11 | $102.33 |