- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $10.42 / $10.42 / $10.42
| Facility | 26 | $10.42 | $10.42 | $10.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.08 / $54.86 / $72.26
| Professional | | $47.08 | $54.86 | $72.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.20 / $36.94 / $103.07
| Professional | | $11.20 | $36.94 | $103.07 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $14.27 / $14.27 / $14.27
| Facility | 26 | $14.27 | $14.27 | $14.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.03 / $78.69 / $103.98
| Professional | | $57.03 | $78.69 | $103.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.94 / $32.34 / $77.45
| Professional | | $17.94 | $32.34 | $77.45 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $14.27 / $14.27 / $14.27
| Facility | 26 | $14.27 | $14.27 | $14.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $59.06 / $86.13 / $136.59
| Professional | | $59.06 | $86.13 | $136.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54.50 / $82.26 / $110.87
| Professional | | $54.50 | $82.26 | $110.87 |