- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $258.29 / $258.29 / $258.29
| Facility | 26 | $258.29 | $258.29 | $258.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.03 / $93.34 / $103.17
| Professional | | $70.03 | $93.34 | $103.17 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $31.45 / $37.81 / $39.90
| Professional | 26 | $31.45 | $37.81 | $39.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.13 / $139.94 / $182.88
| Professional | | $126.13 | $139.94 | $182.88 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $36.27 / $51.81 / $78.84
| Professional | 26 | $36.27 | $51.81 | $78.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.85 / $158.11 / $218.96
| Professional | | $87.85 | $158.11 | $218.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $36.19 / $59.36 / $86.43
| Professional | 26 | $36.19 | $59.36 | $86.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.17 / $135.28 / $185.62
| Professional | | $100.17 | $135.28 | $185.62 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $38.36 / $53.03 / $79.72
| Professional | 26 | $38.36 | $53.03 | $79.72 |