- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $38.59 / $38.59 / $69.19
| Facility | 26 | $38.59 | $38.59 | $69.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.29 / $105.51 / $154.62
| Professional | | $80.29 | $105.51 | $154.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.09 / $119.05 / $216.49
| Professional | | $73.09 | $119.05 | $216.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $76.68 / $117.60 / $221.87
| Professional | | $76.68 | $117.60 | $221.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.61 / $130.75 / $343.52
| Professional | | $105.61 | $130.75 | $343.52 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $43.90 / $51.88 / $136.31
| Professional | 26 | $43.90 | $51.88 | $136.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.42 / $93.32 / $177.79
| Professional | | $42.42 | $93.32 | $177.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.25 / $118.70 / $243.95
| Professional | | $85.25 | $118.70 | $243.95 |