- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $28.28 / $28.28 / $35.58
| Facility | 26 | $28.28 | $28.28 | $35.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $59.67 / $72.56 / $191.08
| Professional | | $59.67 | $72.56 | $191.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.20 / $102.49 / $146.40
| Professional | | $73.20 | $102.49 | $146.40 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $31.61 / $31.61 / $31.61
| Facility | 26 | $31.61 | $31.61 | $31.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.85 / $86.56 / $167.34
| Professional | | $58.85 | $86.56 | $167.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.84 / $127.84 / $135.41
| Professional | | $127.84 | $127.84 | $135.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.38 / $106.41 / $152.02
| Professional | | $86.38 | $106.41 | $152.02 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $33.68 / $41.49 / $59.27
| Professional | 26 | $33.68 | $41.49 | $59.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.13 / $108.33 / $164.27
| Professional | | $72.13 | $108.33 | $164.27 |