- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $52.53 / $54.48 / $67.28
| Facility | 26 | $52.53 | $54.48 | $67.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.20 / $111.47 / $192.41
| Professional | | $90.20 | $111.47 | $192.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.28 / $117.05 / $202.21
| Professional | | $83.28 | $117.05 | $202.21 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $56.98 / $56.98 / $56.98
| Facility | 26 | $56.98 | $56.98 | $56.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.93 / $144.47 / $257.27
| Professional | | $94.93 | $144.47 | $257.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.03 / $139.41 / $254.81
| Professional | | $95.03 | $139.41 | $254.81 |