- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $28.18 / $28.18 / $28.18
| Facility | 26 | $28.18 | $28.18 | $28.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $223.87 / $512.86
| Professional | | $186.21 | $223.87 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $26.92 / $28.84 / $70.79
| Professional | 26 | $26.92 | $28.84 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $812.83 / $812.83
| Professional | | $524.81 | $812.83 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $75.86 / $114.82 / $114.82
| Professional | 26 | $75.86 | $114.82 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $245.47 / $501.19
| Professional | | $245.47 | $245.47 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $41.69 / $41.69 / $81.28
| Professional | 26 | $41.69 | $41.69 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.88 / $398.11 / $588.84
| Professional | | $154.88 | $398.11 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $26.30 / $52.48 / $95.50
| Professional | 26 | $26.30 | $52.48 | $95.50 |