- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $72.93 / $72.93 / $72.93
| Facility | 26 | $72.93 | $72.93 | $72.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.55 / $165.52 / $188.48
| Professional | | $155.55 | $165.52 | $188.48 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $67.59 / $72.93 / $161.37
| Professional | 26 | $67.59 | $72.93 | $161.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.62 / $85.16 / $175.02
| Professional | | $80.62 | $85.16 | $175.02 |
- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $86.87 / $86.87 / $86.87
| Facility | 26 | $86.87 | $86.87 | $86.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.83 / $223.31 / $453.67
| Professional | | $141.83 | $223.31 | $453.67 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $62.48 / $102.23 / $226.87
| Professional | 26 | $62.48 | $102.23 | $226.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.99 / $162.25 / $322.24
| Professional | | $123.99 | $162.25 | $322.24 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $53.05 / $90.71 / $206.32
| Professional | 26 | $53.05 | $90.71 | $206.32 |