- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $85.21 / $85.21 / $85.21
| Facility | 26 | $85.21 | $85.21 | $85.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $171.00 / $277.69 / $328.00
| Professional | | $171.00 | $277.69 | $328.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $51.30 / $85.21 / $98.00
| Professional | 26 | $51.30 | $85.21 | $98.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $71.15 / $71.15 / $71.15
| Professional | 26 | $71.15 | $71.15 | $71.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.35 / $137.65 / $295.32
| Professional | | $91.35 | $137.65 | $295.32 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $45.58 / $62.44 / $73.68
| Professional | 26 | $45.58 | $62.44 | $73.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.29 / $339.24 / $615.61
| Professional | | $167.29 | $339.24 | $615.61 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $48.41 / $81.50 / $155.19
| Professional | 26 | $48.41 | $81.50 | $155.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $175.67 / $234.22 / $529.69
| Professional | | $175.67 | $234.22 | $529.69 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $48.72 / $62.44 / $89.77
| Professional | 26 | $48.72 | $62.44 | $89.77 |