- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $56.66 / $56.66 / $68.28
| Facility | 26 | $56.66 | $56.66 | $68.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.63 / $96.96 / $144.93
| Professional | | $83.63 | $96.96 | $144.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.17 / $93.19 / $97.62
| Professional | | $85.17 | $93.19 | $97.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.77 / $133.44 / $188.37
| Professional | | $96.77 | $133.44 | $188.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.86 / $129.12 / $198.99
| Professional | | $92.86 | $129.12 | $198.99 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $53.60 / $74.53 / $114.86
| Professional | 26 | $53.60 | $74.53 | $114.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.58 / $144.56 / $265.64
| Professional | | $107.58 | $144.56 | $265.64 |