- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $34.67 / $34.67 / $56.23
| Facility | 26 | $34.67 | $34.67 | $56.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.44 / $85.11 / $117.49
| Professional | | $72.44 | $85.11 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $123.03 / $123.03
| Professional | | $123.03 | $123.03 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.86 / $104.71 / $144.54
| Professional | | $75.86 | $104.71 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $33.11 / $33.11
| Professional | | $32.36 | $33.11 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $66.07 / $85.11 / $125.89
| Professional | | $66.07 | $85.11 | $125.89 |