- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $28.46 / $28.46 / $28.46
| Facility | 26 | $28.46 | $28.46 | $28.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.57 / $174.92 / $174.92
| Professional | | $48.57 | $174.92 | $174.92 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $27.12 / $28.46 / $28.46
| Professional | 26 | $27.12 | $28.46 | $28.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.02 / $158.02 / $158.02
| Professional | | $158.02 | $158.02 | $158.02 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $28.27 / $28.27 / $28.27
| Professional | 26 | $28.27 | $28.27 | $28.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.07 / $430.18 / $430.18
| Professional | | $192.07 | $430.18 | $430.18 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $32.38 / $70.48 / $70.48
| Professional | 26 | $32.38 | $70.48 | $70.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.49 / $121.60 / $609.89
| Professional | | $46.49 | $121.60 | $609.89 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $22.54 / $88.95 / $99.94
| Professional | 26 | $22.54 | $88.95 | $99.94 |