- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $38.63 / $38.63 / $38.63
| Facility | 26 | $38.63 | $38.63 | $38.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.29 / $99.94 / $122.75
| Professional | | $80.29 | $99.94 | $122.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.27 / $112.52 / $185.66
| Professional | | $101.27 | $112.52 | $185.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.80 / $279.76 / $450.33
| Professional | | $97.80 | $279.76 | $450.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.60 / $249.98 / $249.98
| Professional | | $110.60 | $249.98 | $249.98 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $41.74 / $91.13 / $91.13
| Professional | 26 | $41.74 | $91.13 | $91.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.09 / $154.19 / $316.56
| Professional | | $63.09 | $154.19 | $316.56 |