- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $32.36 / $32.36 / $32.36
| Facility | 26 | $32.36 | $32.36 | $32.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $66.07 / $83.18 / $114.82
| Professional | | $66.07 | $83.18 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $147.91 / $147.91
| Professional | | $147.91 | $147.91 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.28 / $87.10 / $125.89
| Professional | | $81.28 | $87.10 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.57 / $89.13 / $151.36
| Professional | | $64.57 | $89.13 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $32.36 / $33.11
| Professional | | $32.36 | $32.36 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.66 / $79.43 / $134.90
| Professional | | $61.66 | $79.43 | $134.90 |