- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $47.86 / $47.86 / $47.86
| Facility | 26 | $47.86 | $47.86 | $47.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.72 / $134.90 / $234.42
| Professional | | $97.72 | $134.90 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $33.11 / $54.95 / $102.33
| Professional | 26 | $33.11 | $54.95 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $426.58 / $426.58
| Professional | | $269.15 | $426.58 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $123.03 / $190.55 / $190.55
| Professional | 26 | $123.03 | $190.55 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.49 / $177.83 / $346.74
| Professional | | $117.49 | $177.83 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $38.90 / $70.79 / $102.33
| Professional | 26 | $38.90 | $70.79 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $190.55 / $354.81
| Professional | | $125.89 | $190.55 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $34.67 / $61.66 / $109.65
| Professional | 26 | $34.67 | $61.66 | $109.65 |