- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $23.70 / $23.70 / $23.70
| Facility | 26 | $23.70 | $23.70 | $23.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.76 / $73.78 / $89.00
| Professional | | $55.76 | $73.78 | $89.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $16.47 / $19.19 / $23.70
| Professional | 26 | $16.47 | $19.19 | $23.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.96 / $73.92 / $87.23
| Professional | | $53.96 | $73.92 | $87.23 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $14.38 / $19.70 / $23.25
| Professional | 26 | $14.38 | $19.70 | $23.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.50 / $74.97 / $143.33
| Professional | | $34.50 | $74.97 | $143.33 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $16.80 / $21.76 / $39.09
| Professional | 26 | $16.80 | $21.76 | $39.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.17 / $66.12 / $101.80
| Professional | | $47.17 | $66.12 | $101.80 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $15.02 / $19.54 / $28.86
| Professional | 26 | $15.02 | $19.54 | $28.86 |