- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $172.29 / $172.29 / $172.29
| Facility | 26 | $172.29 | $172.29 | $172.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.20 / $123.41 / $180.73
| Professional | | $103.20 | $123.41 | $180.73 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $58.79 / $69.20 / $101.60
| Professional | 26 | $58.79 | $69.20 | $101.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.52 / $134.72 / $182.21
| Professional | | $86.52 | $134.72 | $182.21 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $56.30 / $80.44 / $119.20
| Professional | 26 | $56.30 | $80.44 | $119.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.15 / $111.15 / $116.10
| Professional | | $111.15 | $111.15 | $116.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.77 / $140.63 / $277.38
| Professional | | $100.77 | $140.63 | $277.38 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $50.08 / $76.83 / $154.16
| Professional | 26 | $50.08 | $76.83 | $154.16 |