- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $178.89 / $178.89 / $178.89
| Facility | 26 | $178.89 | $178.89 | $178.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.63 / $167.48 / $212.87
| Professional | | $142.63 | $167.48 | $212.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $60.96 / $72.18 / $86.33
| Professional | 26 | $60.96 | $72.18 | $86.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.68 / $176.56 / $294.31
| Professional | | $132.68 | $176.56 | $294.31 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $59.76 / $80.78 / $121.78
| Professional | 26 | $59.76 | $80.78 | $121.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.30 / $162.30 / $162.30
| Professional | | $162.30 | $162.30 | $162.30 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $110.90 / $110.90 / $113.18
| Professional | 26 | $110.90 | $110.90 | $113.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.84 / $156.07 / $287.86
| Professional | | $128.84 | $156.07 | $287.86 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $57.38 / $70.34 / $118.47
| Professional | 26 | $57.38 | $70.34 | $118.47 |