- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $153.81 / $153.81 / $153.81
| Facility | 26 | $153.81 | $153.81 | $153.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.43 / $183.36 / $219.94
| Professional | | $51.43 | $183.36 | $219.94 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $13.26 / $17.84 / $95.82
| Professional | 26 | $13.26 | $17.84 | $95.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.01 / $97.78 / $122.64
| Professional | | $35.01 | $97.78 | $122.64 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $21.16 / $30.23 / $34.33
| Professional | 26 | $21.16 | $30.23 | $34.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.57 / $115.83 / $211.55
| Professional | | $91.57 | $115.83 | $211.55 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $20.69 / $35.90 / $51.46
| Professional | 26 | $20.69 | $35.90 | $51.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.06 / $107.79 / $198.54
| Professional | | $75.06 | $107.79 | $198.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $15.79 / $27.69 / $51.60
| Professional | 26 | $15.79 | $27.69 | $51.60 |