- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $44.00 / $51.65 / $51.65
| Facility | 26 | $44.00 | $51.65 | $51.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.10 / $109.88 / $113.22
| Professional | | $93.10 | $109.88 | $113.22 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $33.88 / $38.53 / $39.17
| Professional | 26 | $33.88 | $38.53 | $39.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.50 / $153.51 / $361.44
| Professional | | $87.50 | $153.51 | $361.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $28.70 / $44.73 / $71.76
| Professional | 26 | $28.70 | $44.73 | $71.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.64 / $170.43 / $387.30
| Professional | | $89.64 | $170.43 | $387.30 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $32.47 / $47.23 / $95.48
| Professional | 26 | $32.47 | $47.23 | $95.48 |