- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $125.89 / $125.89 / $125.89
| Facility | 26 | $125.89 | $125.89 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.54 / $81.28 / $208.93
| Professional | | $57.54 | $81.28 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $38.02 / $52.48 / $229.09
| Professional | 26 | $38.02 | $52.48 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.57 / $91.20 / $104.71
| Professional | | $64.57 | $91.20 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $33.88 / $41.69 / $58.88
| Professional | 26 | $33.88 | $41.69 | $58.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.62 / $109.65 / $165.96
| Professional | | $77.62 | $109.65 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $43.65 / $63.10 / $91.20
| Professional | 26 | $43.65 | $63.10 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.18 / $87.10 / $134.90
| Professional | | $69.18 | $87.10 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $40.74 / $54.95 / $77.62
| Professional | 26 | $40.74 | $54.95 | $77.62 |