- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $38.42 / $38.42 / $38.42
| Facility | 26 | $38.42 | $38.42 | $38.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $66.98 / $86.06 / $135.38
| Professional | | $66.98 | $86.06 | $135.38 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $28.36 / $38.04 / $57.17
| Professional | 26 | $28.36 | $38.04 | $57.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.18 / $197.99 / $207.63
| Professional | | $154.18 | $197.99 | $207.63 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $69.34 / $84.32 / $92.45
| Professional | 26 | $69.34 | $84.32 | $92.45 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $184.68 / $369.36 / $413.88
| Professional | 50 | $184.68 | $369.36 | $413.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.05 / $174.17 / $272.17
| Professional | | $91.05 | $174.17 | $272.17 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $43.24 / $77.11 / $119.49
| Professional | 26 | $43.24 | $77.11 | $119.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.30 / $154.24 / $553.27
| Professional | | $89.30 | $154.24 | $553.27 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $41.92 / $71.56 / $234.24
| Professional | 26 | $41.92 | $71.56 | $234.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.62 / $154.24 / $205.67
| Professional | | $86.62 | $154.24 | $205.67 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $38.97 / $68.59 / $90.96
| Professional | 26 | $38.97 | $68.59 | $90.96 |