- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $70.53 / $70.53 / $70.53
| Facility | 26 | $70.53 | $70.53 | $70.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.43 / $123.47 / $166.68
| Professional | | $73.43 | $123.47 | $166.68 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $40.90 / $70.53 / $95.21
| Professional | 26 | $40.90 | $70.53 | $95.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54.66 / $74.87 / $88.35
| Professional | | $54.66 | $74.87 | $88.35 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $28.86 / $39.54 / $46.66
| Professional | 26 | $28.86 | $39.54 | $46.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.78 / $126.11 / $279.08
| Professional | | $83.78 | $126.11 | $279.08 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $45.54 / $66.41 / $155.41
| Professional | 26 | $45.54 | $66.41 | $155.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.06 / $87.65 / $144.96
| Professional | | $64.06 | $87.65 | $144.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $36.00 / $48.95 / $76.80
| Professional | 26 | $36.00 | $48.95 | $76.80 |