- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $72.29 / $72.29 / $72.29
| Facility | 26 | $72.29 | $72.29 | $72.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.25 / $126.42 / $130.16
| Professional | | $114.25 | $126.42 | $130.16 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $65.04 / $69.20 / $72.29
| Professional | 26 | $65.04 | $69.20 | $72.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $283.08 / $283.08 / $408.90
| Professional | | $283.08 | $283.08 | $408.90 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $159.08 / $161.38 / $236.04
| Professional | 26 | $159.08 | $161.38 | $236.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.08 / $162.59 / $408.90
| Professional | | $90.08 | $162.59 | $408.90 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $50.05 / $92.38 / $236.04
| Professional | 26 | $50.05 | $92.38 | $236.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.13 / $163.63 / $276.08
| Professional | | $139.13 | $163.63 | $276.08 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $79.22 / $93.20 / $153.16
| Professional | 26 | $79.22 | $93.20 | $153.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.40 / $176.60 / $501.89
| Professional | | $173.40 | $176.60 | $501.89 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $96.21 / $99.30 / $279.69
| Professional | 26 | $96.21 | $99.30 | $279.69 |