- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $55.22 / $55.23 / $55.23
| Facility | 26 | $55.22 | $55.23 | $55.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.48 / $94.91 / $137.25
| Professional | | $77.48 | $94.91 | $137.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.79 / $124.69 / $234.35
| Professional | | $70.79 | $124.69 | $234.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.34 / $132.53 / $172.39
| Professional | | $102.34 | $132.53 | $172.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.58 / $78.05 / $132.50
| Professional | | $48.58 | $78.05 | $132.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.81 / $109.30 / $194.43
| Professional | | $70.81 | $109.30 | $194.43 |