- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $208.96 / $208.96 / $208.96
| Facility | 26 | $208.96 | $208.96 | $208.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.95 / $123.86 / $135.69
| Professional | | $90.95 | $123.86 | $135.69 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $25.59 / $33.90 / $72.37
| Professional | 26 | $25.59 | $33.90 | $72.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.35 / $132.38 / $253.03
| Professional | | $122.35 | $132.38 | $253.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $41.55 / $59.36 / $65.17
| Professional | 26 | $41.55 | $59.36 | $65.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.32 / $166.33 / $236.58
| Professional | | $97.32 | $166.33 | $236.58 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $40.70 / $69.92 / $98.01
| Professional | 26 | $40.70 | $69.92 | $98.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.38 / $137.16 / $182.90
| Professional | | $72.38 | $137.16 | $182.90 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $31.77 / $43.61 / $92.25
| Professional | 26 | $31.77 | $43.61 | $92.25 |