- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $8.51 / $10.77 / $20.02
| Facility | 26 | $8.51 | $10.77 | $20.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.20 / $78.84 / $116.48
| Professional | | $69.20 | $78.84 | $116.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.86 / $98.19 / $151.27
| Professional | | $73.86 | $98.19 | $151.27 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $10.06 / $10.06 / $10.06
| Facility | 26 | $10.06 | $10.06 | $10.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $82.61 / $115.80 / $187.48
| Professional | | $82.61 | $115.80 | $187.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.63 / $94.86 / $165.87
| Professional | | $72.63 | $94.86 | $165.87 |