- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $27.90 / $29.23 / $32.79
| Facility | 26 | $27.90 | $29.23 | $32.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.74 / $157.71 / $208.48
| Professional | | $122.74 | $157.71 | $208.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.05 / $150.81 / $278.85
| Professional | | $101.05 | $150.81 | $278.85 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $30.71 / $30.71 / $30.71
| Facility | 26 | $30.71 | $30.71 | $30.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $99.88 / $182.57 / $332.34
| Professional | | $99.88 | $182.57 | $332.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.28 / $163.71 / $304.57
| Professional | | $104.28 | $163.71 | $304.57 |