- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $80.47 / $80.47 / $80.47
| Facility | 26 | $80.47 | $80.47 | $80.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.31 / $118.82 / $145.91
| Professional | | $105.31 | $118.82 | $145.91 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $61.41 / $66.08 / $93.19
| Professional | 26 | $61.41 | $66.08 | $93.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.53 / $110.03 / $165.04
| Professional | | $93.53 | $110.03 | $165.04 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $44.84 / $64.05 / $78.05
| Professional | 26 | $44.84 | $64.05 | $78.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.02 / $119.13 / $248.15
| Professional | | $81.02 | $119.13 | $248.15 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $67.69 / $81.27 / $145.94
| Professional | 26 | $67.69 | $81.27 | $145.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.53 / $148.33 / $225.72
| Professional | | $122.53 | $148.33 | $225.72 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $64.31 / $82.17 / $114.32
| Professional | 26 | $64.31 | $82.17 | $114.32 |