- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $25.51 / $25.51 / $25.51
| Facility | 26 | $25.51 | $25.51 | $25.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.57 / $137.65 / $178.36
| Professional | | $48.57 | $137.65 | $178.36 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $20.62 / $27.12 / $31.22
| Professional | 26 | $20.62 | $27.12 | $31.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.80 / $56.28 / $193.20
| Professional | | $30.80 | $56.28 | $193.20 |
- 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
- Facility
- Modifier
- 26
- Low / Median / High Price
- $60.51 / $158.69 / $158.69
| Facility | 26 | $60.51 | $158.69 | $158.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $62.13 / $107.51 / $1,146.60
| Professional | | $62.13 | $107.51 | $1,146.60 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $27.26 / $34.58 / $196.77
| Professional | 26 | $27.26 | $34.58 | $196.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $65.40 / $101.54 / $181.52
| Professional | | $65.40 | $101.54 | $181.52 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $27.26 / $34.58 / $41.71
| Professional | 26 | $27.26 | $34.58 | $41.71 |