- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $258.45 / $258.45 / $258.45
| Facility | 26 | $258.45 | $258.45 | $258.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $76.33 / $129.88 / $139.77
| Professional | | $76.33 | $129.88 | $139.77 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $31.93 / $38.78 / $40.95
| Professional | 26 | $31.93 | $38.78 | $40.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.90 / $138.63 / $203.78
| Professional | | $124.90 | $138.63 | $203.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $34.15 / $48.80 / $82.99
| Professional | 26 | $34.15 | $48.80 | $82.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.72 / $169.80 / $316.89
| Professional | | $88.72 | $169.80 | $316.89 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $37.52 / $59.34 / $86.49
| Professional | 26 | $37.52 | $59.34 | $86.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.78 / $154.29 / $369.73
| Professional | | $107.78 | $154.29 | $369.73 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $36.28 / $48.04 / $90.62
| Professional | 26 | $36.28 | $48.04 | $90.62 |