- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $48.80 / $48.80 / $48.80
| Facility | 26 | $48.80 | $48.80 | $48.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.07 / $66.59 / $82.19
| Professional | | $56.07 | $66.59 | $82.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $38.90 / $46.46 / $57.33
| Professional | 26 | $38.90 | $46.46 | $57.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.70 / $87.23 / $127.19
| Professional | | $60.70 | $87.23 | $127.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $43.43 / $59.04 / $86.28
| Professional | 26 | $43.43 | $59.04 | $86.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.70 / $93.15 / $124.74
| Professional | | $70.70 | $93.15 | $124.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $50.11 / $65.00 / $88.15
| Professional | 26 | $50.11 | $65.00 | $88.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.90 / $94.42 / $151.97
| Professional | | $67.90 | $94.42 | $151.97 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $46.16 / $62.87 / $96.71
| Professional | 26 | $46.16 | $62.87 | $96.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.00 / $93.79 / $168.26
| Professional | | $72.00 | $93.79 | $168.26 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $49.65 / $66.69 / $126.62
| Professional | 26 | $49.65 | $66.69 | $126.62 |