- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $331.13 / $331.13 / $331.13
| Facility | 26 | $331.13 | $331.13 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.61 / $87.10 / $478.63
| Professional | | $67.61 | $87.10 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $48.98 / $66.07 / $208.93
| Professional | 26 | $48.98 | $66.07 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $112.20 / $154.88
| Professional | | $79.43 | $112.20 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $56.23 / $63.10 / $109.65
| Professional | 26 | $56.23 | $63.10 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.13 / $162.18 / $363.08
| Professional | | $74.13 | $162.18 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $52.48 / $91.20 / $141.25
| Professional | 26 | $52.48 | $91.20 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.28 / $138.04 / $295.12
| Professional | | $81.28 | $138.04 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $58.88 / $81.28 / $123.03
| Professional | 26 | $58.88 | $81.28 | $123.03 |