- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $55.42 / $55.42 / $55.42
| Facility | 26 | $55.42 | $55.42 | $55.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.69 / $244.36 / $258.44
| Professional | | $194.69 | $244.36 | $258.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $42.78 / $55.42 / $66.29
| Professional | 26 | $42.78 | $55.42 | $66.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $202.12 / $276.87 / $326.70
| Professional | | $202.12 | $276.87 | $326.70 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $35.56 / $48.71 / $57.48
| Professional | 26 | $35.56 | $48.71 | $57.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $189.39 / $241.85 / $440.19
| Professional | | $189.39 | $241.85 | $440.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $42.81 / $55.77 / $104.37
| Professional | 26 | $42.81 | $55.77 | $104.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.27 / $218.96 / $290.58
| Professional | | $167.27 | $218.96 | $290.58 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $41.69 / $53.15 / $73.79
| Professional | 26 | $41.69 | $53.15 | $73.79 |