- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $11.38 / $11.38 / $19.16
| Facility | 26 | $11.38 | $11.38 | $19.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.78 / $62.57 / $86.55
| Professional | | $48.78 | $62.57 | $86.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.00 / $106.00 / $106.00
| Professional | | $106.00 | $106.00 | $106.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $49.18 / $69.13 / $107.70
| Professional | | $49.18 | $69.13 | $107.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $32.34
| Professional | | $32.34 | $32.34 | $32.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.55 / $57.53 / $105.96
| Professional | | $44.55 | $57.53 | $105.96 |