- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $38.90 / $38.90 / $38.90
| Facility | 26 | $38.90 | $38.90 | $38.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.13 / $123.03 / $257.04
| Professional | | $89.13 | $123.03 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $30.20 / $48.98 / $104.71
| Professional | 26 | $30.20 | $48.98 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.72 / $138.04 / $204.17
| Professional | | $97.72 | $138.04 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $30.90 / $60.26 / $79.43
| Professional | 26 | $30.90 | $60.26 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $144.54 / $239.88
| Professional | | $102.33 | $144.54 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $34.67 / $61.66 / $123.03
| Professional | 26 | $34.67 | $61.66 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.82 / $162.18 / $309.03
| Professional | | $128.82 | $162.18 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $57.54 / $72.44 / $138.04
| Professional | 26 | $57.54 | $72.44 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $134.90 / $323.59
| Professional | | $102.33 | $134.90 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $32.36 / $57.54 / $117.49
| Professional | 26 | $32.36 | $57.54 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $158.49 / $302.00
| Professional | | $102.33 | $158.49 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $33.88 / $56.23 / $100.00
| Professional | 26 | $33.88 | $56.23 | $100.00 |