- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $6.03 / $6.03 / $6.03
| Facility | 26 | $6.03 | $6.03 | $6.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.70 / $30.90 / $57.54
| Professional | | $25.70 | $30.90 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $32.36 / $32.36
| Professional | | $32.36 | $32.36 | $32.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.88 / $43.65 / $61.66
| Professional | | $33.88 | $43.65 | $61.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $40.74 / $66.07
| Professional | | $30.20 | $40.74 | $66.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $32.36 / $33.11
| Professional | | $32.36 | $32.36 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.12 / $38.02 / $66.07
| Professional | | $25.12 | $38.02 | $66.07 |