- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $66.20 / $66.20 / $80.13
| Facility | 26 | $66.20 | $66.20 | $80.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.34 / $139.47 / $200.48
| Professional | | $108.34 | $139.47 | $200.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.53 / $183.61 / $275.41
| Professional | | $112.53 | $183.61 | $275.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.17 / $179.32 / $278.95
| Professional | | $111.17 | $179.32 | $278.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.93 / $188.48 / $282.70
| Professional | | $131.93 | $188.48 | $282.70 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $62.62 / $87.07 / $134.19
| Professional | 26 | $62.62 | $87.07 | $134.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.68 / $182.50 / $329.14
| Professional | | $127.68 | $182.50 | $329.14 |