- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $20.03 / $20.03 / $21.64
| Facility | 26 | $20.03 | $20.03 | $21.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.31 / $84.86 / $127.74
| Professional | | $58.31 | $84.86 | $127.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.10 / $85.56 / $127.98
| Professional | | $42.10 | $85.56 | $127.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.11 / $95.14 / $154.96
| Professional | | $32.11 | $95.14 | $154.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.76 / $101.03 / $136.53
| Professional | | $0.76 | $101.03 | $136.53 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $0.28 / $22.54 / $30.97
| Professional | 26 | $0.28 | $22.54 | $30.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.76 / $77.48 / $129.62
| Professional | | $0.76 | $77.48 | $129.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.76 / $84.75 / $161.28
| Professional | | $36.76 | $84.75 | $161.28 |