- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $29.08 / $29.66 / $33.46
| Facility | 26 | $29.08 | $29.66 | $33.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.94 / $172.56 / $260.94
| Professional | | $138.94 | $172.56 | $260.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.97 / $164.52 / $303.48
| Professional | | $102.97 | $164.52 | $303.48 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $31.43 / $31.43 / $31.43
| Facility | 26 | $31.43 | $31.43 | $31.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.95 / $200.30 / $370.67
| Professional | | $100.95 | $200.30 | $370.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.62 / $174.66 / $319.57
| Professional | | $106.62 | $174.66 | $319.57 |