- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $117.49 / $117.49 / $117.49
| Facility | 26 | $117.49 | $117.49 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.11 / $120.23 / $331.13
| Professional | | $85.11 | $120.23 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $18.20 / $23.99 / $57.54
| Professional | 26 | $18.20 | $23.99 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $165.96 / $239.88
| Professional | | $125.89 | $165.96 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $19.50 / $28.18 / $47.86
| Professional | 26 | $19.50 | $28.18 | $47.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $208.93 / $309.03
| Professional | | $100.00 | $208.93 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $19.05 / $42.66 / $51.29
| Professional | 26 | $19.05 | $42.66 | $51.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.18 / $141.25 / $229.09
| Professional | | $83.18 | $141.25 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $22.39 / $28.18 / $45.71
| Professional | 26 | $22.39 | $28.18 | $45.71 |