- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $89.13 / $89.13 / $89.13
| Facility | 26 | $89.13 | $89.13 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.12 / $114.82 / $275.42
| Professional | | $50.12 | $114.82 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $15.85 / $47.86 / $95.50
| Professional | 26 | $15.85 | $47.86 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54.95 / $97.72 / $128.82
| Professional | | $54.95 | $97.72 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $21.38 / $29.51 / $38.90
| Professional | 26 | $21.38 | $29.51 | $38.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.86 / $147.91 / $245.47
| Professional | | $75.86 | $147.91 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $15.49 / $35.48 / $52.48
| Professional | 26 | $15.49 | $35.48 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.86 / $107.15 / $199.53
| Professional | | $75.86 | $107.15 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $16.60 / $26.92 / $48.98
| Professional | 26 | $16.60 | $26.92 | $48.98 |