- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $10.96 / $10.96 / $16.98
| Facility | 26 | $10.96 | $10.96 | $16.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.66 / $52.48 / $81.28
| Professional | | $42.66 | $52.48 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.81 / $39.81 / $39.81
| Professional | | $39.81 | $39.81 | $39.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $107.15 / $107.15
| Professional | | $107.15 | $107.15 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.86 / $67.61 / $102.33
| Professional | | $47.86 | $67.61 | $102.33 |
- 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
- $42.66 / $57.54 / $109.65
| Professional | | $42.66 | $57.54 | $109.65 |