- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $42.66 / $151.36 / $177.83
| Facility | 26 | $42.66 | $151.36 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $66.07 / $85.11 / $154.88
| Professional | | $66.07 | $85.11 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.57 / $109.65 / $165.96
| Professional | | $64.57 | $109.65 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $117.49 / $257.04
| Professional | | $79.43 | $117.49 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.13 / $123.03 / $177.83
| Professional | | $89.13 | $123.03 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.44 / $104.71 / $223.87
| Professional | | $72.44 | $104.71 | $223.87 |